Chapter 02. Laparoscopic Treatment of Inguinal Hernias. 2 Laparoendoscopic Surgery. Mihaileanu Florin and Florin Zaharie*

Transcription

1 Chapter 02 Laparoscopic Treatment of Inguinal Hernias Mihaileanu Florin and Florin Zaharie* University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Romania * Corresponding Author: Zaharie Florin, University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Romania, florinzaharie@ yahoo.com First Published February 23, 2018 Copyright: 2018 Mihaileanu Florin and Florin Zaharie. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source. 2

2 Hernia is defined as the protrusion of a viscera or anatomical tissue through an existing or acquired hole of the abdominal wall. We actually talk about hernia whenever there is a defect in the posterior inguinal wall, either congenital or acquired. The hernia definition should also take into account the incipient, clinically non-manifest stages in which we have only the protrusion of the peritoneum through a minor parietal defect, but which by the presence of the hernia sac causes the occurrence of the manifest clinical hernia. Hernia is a pathology commonly encountered in surgical pathology, particularly affecting males; the literature showing over 2 million cases per year [1]. Since recurrent hernias and complex hernias have been successfully solved by posterior approach by Stoppa and Nyhus, placing a polypropylene mesh in the preperitoneal space, the laparoscopic approach of inguinal hernias represented a new therapeutic option. The laparoscopic method does not change the treatment of various surgical pathologies, but rather, the new approach is responsible for the much easier postoperative recovery of patients. The development of laparoscopic surgery is due to technical evolution, in particular 2 essential factors: the development of the optical lens system and the use of fiber-optic light sources, which, when connected to performance monitors, provide a highly accurate image of the inguinal area anatomy. The technical development enables the surgeon and helpers to handle the endoscope by actively taking part in the operative technique. Although the number of laparoscopic interventions for hernia has been on an ascending curve since 1991, since the method was introduced, they remain only 15-20% of the total hernias operated. Laparoscopy remains a difficult technique, the method being performed only by surgeons with special laparoscopic abilities [2,3 ]. 3

3 A first step is to understand the anatomy of the inguinal region from the perspective of the region s posterior wall. The muscles of the inguinal region are represented by 3 muscular aponeurotic structures that close the inguinal space. Superficially, the external oblique muscle becomes completely aponeurotic in the inguinal region, forming an aponeurotic orifice near the pubic tubercle which represents the inguinal external ring through which the spermatic cord passes, in males, or the round ligament, in females. The lower part of external oblique muscle aponeurosis represents the inguinal ligament that extends from the anterior - superior iliac spine to the pubic tubercle. The next muscle layer is represented by the internal oblique muscle located between the superficial layer (external oblique muscle) and the deep muscle layer represented by the abdominal transverse muscle. Lower inferior fibers originating in the inguinal ligament form the cremaster muscle. The abdominal transverse muscle represents the deepest layer of the abdominal wall in the lower part, ending in a curve that delimits the myopectineal opening. The dorsal part of the transverse abdominal muscle is covered by fascia transversalis which closes the myopectineal orifice. The lower margin of the fascia transversalis forms the ilio-pubic tract that extends from the anterior - superior iliac spine to the linea pectineata of the pubis. Superior fascia presents a split through which the inferior epigastric vascular cord goes down [4]. In laparoscopic surgery, the surgeon enters the preperitoneal space both by transabdominal preperitoneal patch (TAPP) as well extraperitoneal patch (TEP) total approach. The main anatomical elements to be identified are the bladder, the ductus deferens, the spermatic cord, the external iliac vascular vessel and the inferior vascular epigastric vessel. 4

4 The correct dissection plane is the avascular plane located immediately behind the abdominal muscle. Incorrect dissection penetrates the space between the preperitoneal fat and the posterior lamella of the fascia transversalis that contains many small vessels that can be damaged. Figure 1: Anatomy of inguinal region (posterior view) [5]. The vascularization of the inguinal region in the laparoscopic approach is represented by the external iliac vessel (vein and artery) and the lower epigastric vessel. The epigastric artery with the origin at the external iliac artery has an upward course between the lamellae of the fascia transversalis and makes anastomosis with the superior epigastric artery originated in the internal mammary artery. Inconstantly, there is the suprapubic vascular anastomosis known as corona mortis originating in the inferior epigastric artery or the external iliac artery and the anastomosis of which is made with the obturatory artery, the branch of hypogastric artery descending to the obturating hole. 5

5 The triangle of death is a risk area that encompasses the large vessels (external iliac artery and vein) being delimited by the ductus deferens, with medial location and the spermatic cord, laterally. The pro-peritoneal space communicates directly with the Retzius retropubic space. At this level, the Cooper ligament can be identified, ranging from the pubic tubercle to the ileo pectinee eminence, making an angle of 30 0 along with the inguinal ligament. Figure 2: Lower epigastric vessel. Figure 3: Pubic symphysis - Cooper ligament. 6

6 Laparoscopic exploration allows the identification of the three nerves of the inguinal region: the lateral cutaneous femoral nerve, the femoral nerve and the genitofemoral nerve. The femoral nerve is the largest nerve identified at this level. It innervates the motor muscle of the anterior compartment of the thigh and sensitively the skin of the anterior -medial region of the thigh and foot. The superficial cutaneous femoral nerve originates on the lateral edge of the psoas muscle and then, it has a descending course innervating the skin of the lateral and anterior parts of the thigh, on an average of 1/3. The genitofemoral nerve divides on the anterior part of the psoas muscle behind the deep inguinal orifice, in 2 genital and femoral branches. The femoral branches provide the sensory innervation of the anterior region of the thigh. The genital branch enters the inguinal canal and provides the sensitive and motoric innervation of the scrotum and the cremaster muscle, and in females, the labial area. Lateral to the spermatic cord and medially to the inguinal ligament, these nerves will form a risk area for the damage of the innervation of the inguinal region known as the pain triangle. Abusive use of electrodissection or application of fixation tacks can cause irreversible lesions with lack of cutaneous sensitivity or postoperative inguinodynia. 7

7 Figure 4: Doom triangle and triangle of pain [6]. Classification of Hernias There are many variants of hernia classification, but from a practical point of view we have to choose a simple and logical, easily reproducible variant that allows a common surgical strategy. In this regard, the European Hernia Society (EAS) has presented a new classification that takes into account the topography and the size of the parietal orifice. Providing a common and easy terminology, the EAS classification allows a much easier evaluation of preoperative patients and quantification of postoperative outcomes. 8

8 Table 1: Classification of inguinal hernias Lateral (L) Medial (M) Femoral (F) (non-detectable) (<1.5 cm=1 finger) (1.5-3 cm=2 fingers) (>3cm=3 fingers) Preoperative Preparation The Diet From the point of view of preoperative food restrictions, we only refer to the restriction of food and beverages which by fermentation can cause abdominal meteorism, thus reducing the operating field. The patient will be asked to avoid such foods one day before the operation and on the operation day any ingestion of liquid and food shall be forbidden. Antibiotic Prophylaxis The EAS guidelines have shown that there are no differences in the risk of septic complications in patients who have been treated with antibiotics compared to those who have not been administered antibiotics. As a consequence, it is not necessary to administer antibiotics in patients with hernial pathology who will undergo laparoscopy procedure [7]. Patients with immunosuppression, patients with diabetes, neoplastic patients or those with prosthetic heart valves who are given 3 doses of antibiotic (cephalosporine) one day before surgery, 2 hours before surgery, and anesthetic induction are excluded. Anticoagulant Treatment Since laparoscopic surgery involves general anesthesia and the establishment of pneumoperitoneum in the case of TAPP, anticoagu- 9

9 lant prophylaxis is required by the administration of a heparin dose of low molecular weight, hours before surgery. The presence of (cardiac, pulmonary) co-morbidities requires continued postoperative anticoagulant treatment up to 3 weeks according to the European guidelines and upon the anesthetist s indication. If the patient is under chronic treatment with oral anticoagulants, the administration of these will be discontinued and anticoagulants with low molecular weight shall be administered. Urinary Catheterization The dissection of the prevesical space in the laparoscopic approach is a difficult procedure especially when the bladder is not empty. In the TAPP technique, bladder emptying before surgery often provides sufficient dissection space, so urinary catheterization is not required. This is only required in patients with known prostate pathology, or those associated with associated defects that require closer monitoring of intra and postoperative diuresis. For the TEP approach, the dissection space much lower compared to TAPP requires routine urinary catheterization of patients, all the more so when the surgeon is in the learning curve, when operating times are much extended. Urinary catheter is maintained for hours after surgery and antibiotic prophylaxis is required. Paraclinical Tests Before surgery, blood samples (for liver, kidney, blood glucose tests, complete blood count, leukocytes) and clotting samples are collected in all patients, and the biochemical balance is mandatory before any general anesthesia. Patients over 40 years of age will have an electrocardiogram and those with known cardiac pathology, at the advice of the anesthetist, will also undergo a specialty cardiology consultation. 10

10 Chest radiography will be performed routinely even more if the patient is a smoker, elderly or known chronic lung disease. Instruments For the laparoscopic approach of the inguinal hernia, common instruments with other types of laparoscopy are needed. The technical development of dissection instruments and electro-coagulation devices has allowed a much easier approach to dissection planes and much faster and more efficient hemostasis. The disposable instruments have reduced the risk of infections but have increased the costs of surgery. Required tools: Veress needle to establish pneumoperitoneum in the TAPP approach Dissection balloon or Hasson trocar for the properitoneal cavity dissection for the TEP approach Trocars of 10 mm for telescope and trocars of 5 mm for dissection forceps Clip applicator and tack applicator for mesh fixation Atraumatic grasper and monopolar scissors Scalpel blade, Farabeuf retractors, Metzenbaum scissors, Mayo or Overholt forceps, Mayo-Hegar needle holder Endoscope of 0 or 30 grd 15x15 cm mesh Operating Room / Position on the Operating Table The patient is placed in dorsal decubitus with the hands along the body so that not to disturb the operating team. After general anesthesia, the patient is positioned in Trendelenburg position, inclined at the opposite side of the hernia in a 15-degree angle that allows a 11

11 better exposure of the inguinal region, in the TAPP variant, helping to remove intestinal loop from the operating field. The surgeon is placed contralateral to the hernia and the cameraman according to the approach, TEP or TAPP, on the same side with the surgeon or in front of him. The monitor is located at the patient s feet and the anesthetist at the head of the patient. Choosing the Operating Technique Due to the smaller space of dissection characteristic of total extraperitoneal technique, we encounter more often a higher learning curve compared to the TAPP technique. Ideally, the surgeon should be familiar with both the TAPP and TEP operating techniques, thus being able to make individualized decisions for each individual patient. Studies in literature have tried to determine which of these two methods would represent the optimal variant for laparoscopic surgery. Intraoperative complications were more common in patients treated with TEP, but severe vascular and visceral complications were more common in patients operated on treated with TAPP technique. During the learning period, the operating time was higher for the TEP technique but once the learning curve was reached, the operating times became sensitively equal. The costs of the surgery are higher for the TEP technique due to the use of the dissection balloon, but the lack of mesh fixation and shorter hospitalization time improve the costs. In conclusion, both methods are safe and effective for inguinal hernia patients [ 8,9 ]. 12

12 Table 2: TAPP/TEP. Method TAPP TEP Standard access + - Complete inspection of the abdomen + - Strangled hernias + - Risk of visceral lesions + - Occurrence of adhesions + - Longer operating time + - Higher learning curve - + Reproducibility + - Costs (fixing the mesh) + - Serious complications + - Management of complications + - Incisions inferior abdomen - transversal + - Incisions inferior abdomen - vertical + + Bilateral hernia + + Figure 5: The choice algorithm of the operating technique. The choice of the method will be finally done based on the experience of the surgical team and the indications of general anesthesia. 13

13 Total Extraperitoneal Approach: TEP Technique To choose this surgical option, it is imperative for the surgeon to have an advanced level in laparoscopic surgery. Due to the not so familiar approach of the preperitoneal cavity, compared to the intraperitoneal area that any general surgeon knows very well, a much longer learning curve is needed in the TEP technique. The TEP approach is a much faster method of solving inguinal hernias once the technique is mastered and the anatomy of the preperitoneal cavity is well known, to which we add the absence of the risk of injuring the intra-abdominal organs. Incision We chose a transversal subumbilical incision of cm, paramedian on the side of the hernia, and in case of bilateral hernias on the part of the dominant hernia. Thus, we avoid the median line where the shears of the rectus muscle converge, thus risking the peritoneal perforation and loss of the operative space. Another option would be a contralateral paramedian incision which, according to some authors, would allow a larger dissection space. After performing the incision, we perform the dissection in the subcutaneous space and with the dissecting scissors we penetrate the anterior lamella of the rectus muscle. With an applied swab, we make a blunt dissection of this area, paying close attention to the hemostasis of the small vessels found at this level, a bleeding in the fatty layer of the subcutaneous tissue causing difficulty in orientation. By means of two Farabeuf retractors, we have a sufficiently large operative field to allow us to identify the white fibers of the sheath of the rectus muscle. Using the scalpel we make a transversal incision on the anterior lamella of the rectus muscle, exposing the fibers of the 14

14 rectus muscle which are located below. The lateral traction of these fibers by means of a retractor or an Overholt forceps allows the exposure of the posterior lamella of the rectus muscle. The existence of the dissector balloon makes it easy to the avascular penetration through the retromuscular space and the creation of a suitable work area. The trocar is directed to the pubic area and when we identify by palpation the pubic symphysis, we inflate the balloon, which will thus non-traumatically dissect the entire preperitoneal space. Due to the transparency of this type of trocar, we can see the phase of the dissection by inserting the telescope in the trocar. After dissection is complete, we replace the ballon trocar with a Hasson trocar of 10 mm that allows the sealing of the extraperitoneal tunnel. In the absence of the Hasson trocar, we use a 10 mm trocar that is sealed either by applying a thread to the front of the anterior abdominal muscle coverage or by using two Backhaus clamps on the skin. If we do not have a dissection balloon trocar, we will use a finger that is inserted into the retromuscular space allowing a relatively safe dissection of the space. The possible incidents in this work would be accidental perforation of the peritoneum requiring discontinuation of the technique and conversion to TAPP or open surgery, or hemorrhagic lesions, that can be difficult to manage due to the absence of direct visualization. The dissection is then continued by means of the telescope that is pushed towards the pubic symphysis, creating an extraperitoneal tunnel wide enough to allow the insertion of the other trocars. After inserting the optical trocar, we attach the CO2 injector at a pressure of 12 mmhg. We chose the technique of placing the trocars on the median line using a 10 mm trocar approximately at half of the distance of the pubic-umbilicus and a 5 mm trocar suprapubian. It should be placed as far as possible at 3 fingers below the median trocar to avoid the interlacing of the tools and sufficiently upward to the 15

15 pubic symphysis not to interfere with the placement of the polypropylene mesh. Direct viewing of the trocars insertion procedure avoids unwanted lesions of epigastric branches or accidental peritoneal or bladder perforation. A technical option would be placing the 5 mm trocar in the ispsilateral flank, 2nd help surgeon located on the opposite side of the surgeon. Figure 6: Position of the trocars [10]. The dissection of the retromuscular space begins at the pubis with the removal of the remaining tissues, in an attempt to identify the anatomical markers. We follow the release of the pubic symphysis and the Cooper ligament that appear in a bright white color, of tough consistency at instrumental palpation. At this level we identify direct hernias that can be reduced at this time. Often, a gentle traction of the peritoneum oriented to the posterior and a counter-traction on the fascia transversalis releases the direct hernial orifice. The dissection continues laterally to identify the inferior epigastric vessel. After identifying the inferior epigastric vessel, we will dissect all the fatty cells and connective tissues from the abdominal wall until we identify the peritoneum that is pulled toward the posterior. 16

16 The fascia structures present are removed by traction or by means of electrocautery, continuing the dissection to the lateral area of the inguinal space. At this level, we identify the Douglas line which, if is not isolated by balloon dissection, is immediately cut at its insertion into the muscle wall with the intention of obtaining a broader operative field. A possible incident is the accidental perforation of the peritoneum with the loss of operating space. To solve the incident, we introduce a Veress needle, transperitoneal, or if the lesion is larger, a 5 mm trocar, these acting as the exhaust valve. We will also inspect the femoral area to exclude femoral hernias. The external iliac vein is laterally by the Cooper ligament, in the case of a hernia, the vein being located under the hernial sac. The traction on the sac releases the hernial orifice, but in the case of a strangled hernia, we will make an incision on the super-medial edge of the femoral ring to release the hernial sac. Sometimes we can see the presence of a prehernial lipoma. It is drawn from the deep inguinal orifice with the atraumatic grasper and isolated with the dissection scissors being brought back to the retroperitoneal space. This lipoma is usually identified laterally by the spermatic cord and hernial sac. Therefore, the lateral dissection should be performed until the fibers of the ilio-pubic tract are seen. Attention to genital femoral nerve branches and lateral cutaneous femoral nerve found at this level. 17

17 Figure 7: Lateral dissection. Figure 8: Release of the deep inguinal orifice. 18

18 Figure 9: Prehernial lipoma. If an indirect hernia is present, the sac is identified at this time, being most often located anteriorly and laterally of the spermatic cord, at the lower edge of the deep inguinal orifice. The dissection is done at this level by traction and contra-traction with atraumatic grasper or using the monopolar scissors. Sometimes, in the case of large hernias, the hernial sac is inlaid with the elements of the spermatic cord (the ductus deferens and the testicular vessels) so that the dissection is more difficult, requiring increased attention not to injure these anatomical elements. The dissection of the hernial sac will be made as far as possible to prevent herniated relapse by lifting the lower edge of the prosthesis. We will also release all the adhesions on the medial face of the ductus deferens by obtaining a lateralisation of the spermatic cord, preventing the movement of the prosthesis by the medial peritoneum at the moment of collapse. In the case of large hernial sacs, the dissection being difficult, we can chose the ligature or clipping, and then release it from the chord elements disposed lower and medial from the hernial sac. 19

19 Figures : 10 Figures 10-11: Dissection of the hernial sac. 20

20 Placing the Polypropylene Mesh After the full dissection of the sac, with the release of the deep inguinal orifice, the lateralisation of the spermatic cord and the distal descent of the peritoneum and the sac, the prosthesis of the inguinal area shall be done. We generally use 15/10 cm polypropylene prostheses, which are then tailored to the anatomical features. The new polypropylene prostheses are effective, with variable sizes, having the shape of the wall of the inguinal canal, making them easier to handle and placed at this level. The insertion of the mesh is made by the 10 mm trocar, which has been previously rolled and inserted by means of the 5 mm atraumatic grasper. Once introduced into the preperitoneal space, it is oriented towards the lateral extremity, towards the hernial area, and lower towards the pubis. The advantage of laparoscopic technique is that this prosthesis of approximately 15/10 cm is located so that it exceeds 2 cm below the pubic symphysis, the Cooper ligament and inguinal ligament covering all the weak areas of the inguinal-femoral canal (deep inguinal orifice, femoral ring, medial wall of the inguinal canal). This way, we decrease the risk of another hernia at this level. 21

21 Figure 12: Rolling of the inferior side. Figure 13: Rolling of the superior side. 22

22 In case of bilateral hernias, we will use two polypropylene meshes of approximately 15/10 cm that will be overlapped on the median line. In our experience the meshes did not require parietal fixation being maintained in position by the intraabdominal pressure. Regular controls did not show any hernia relapse after this technique [11]. Fixation was however required in the case of direct large hernias that were fixed at three or four points by means of resorbable tacks preventing the mesh from slipping into the hernial defect. We also chose to fix the fascia transversalis to the Cooper ligament by means of the tacks, thus preventing the postoperative seroma. Other authors consider it necessary to fix the mesh to prevent its mobilization on the evacuation of the gas or immediately after surgery, on the mobilization or after coughing. The fixation in this case is done by applying some tacks directly through the mesh, at the level of Copper ligament and superior - medial in the abdominal wall. This maneuver fixes medially the mesh preventing its rotation. To the lateral, it is fixed to the anterior-superior iliac spine, respectively inferior-lateral. At this level, care must be taken to the pain triangle, as this drill may to damage the present nerve branches. Recognition of the iliac-pubic tract is essential to avoid such incidents. It is in the form of white, fibrous, bright bands that are arranged at the bottom of the deep inguinal orifice. From the exterior of the abdominal wall, in the homoleteral flank of the hernia, we perform hand pressure and counter-pressure from the inside of the abdomen through the tack applicator. This creates a perpendicular arrangement of the instrument on the abdominal wall, making it easier and safer to pull. If we do not feel the instrument, it means that it is lower than the iliac-pubic tract, in the area of the nerve branches and we will avoid pulling the tacks. 23

23 To avoid such incidents, some surgeons chose to use biological (fibrin) or synthetic (cyanoacrylate) adhesives. Biological adhesives have certain disadvantages: they are biologically produced, with infectious risk and high costs, with special storage and use conditions. Cyanoacrylates (Glubran Histoacryl) by rapid polymerization turn into inert products without tissue toxicity. They are easy to apply and have low costs. After placing the mesh in the position, the final aspect is always checked to ensure that the hernial sac is behind the mesh and the lower edge of the mesh is not lifted up. We chose the routine drainage of the preperitoneal space to avoid seroma and postoperative hematoma. After hours the drain is taken out. The presence of an immediate postoperative fluid environment in the preperitoneal space can cause the mobilization of the prosthesis, especially if it has not been previously fixed, and a residual hematoma can cause prosthesis infection and compromise the surgery. Figure 14: Sac placed behind the mesh. 24

24 Figure 15: Postoperative drainage. The evacuation of the gas of the space is done slowly through the 5 mm trocar, aiming to cover the prosthesis by lifting the peritoneum. The rest of the trocars are suppressed and below umbilicus, the anterior lamella of the rectus muscle is closed by applying separate suture points. Intraoperative Incidents At the time of preperitoneal space dissection, whether we use balloon dissection or digital dissection, we can lower the inferior epigastric vessel from the abdominal wall or we can perforate the peritoneum. Also, the blind dissection of this area may cause bleeding by breaking down some of the vessels at this level. The lowering of the epigastric patch makes it difficult to carry out the surgery, sometimes requiring ligation (clipping) and cutting it to create dissection space. The bleeding from small vessels can be controlled by electrocautery, sometimes simple compression with a mounted buffer being 25

25 enough to stop bleeding. For larger hemorrhages we can apply metal clips. Peritoneal perforation is the most difficult to manage. In the case of punctured perforations, the insertion of a Veress transperitoneal needle equalizes the pressures while maintaining the working chamber. Sometimes it may be necessary to insert transperitoneally a 5 mm trocar. Larger lesions of the peritoneum can be solved by applying clips, endoloop or suture. Failure to close peritoneal openings requires conversion to TAPP or open technique. The Transabdominal Preperitoneal Approach: TAAP Technique TAPP is the laparoscopic technique most commonly used for the treatment of inguinal hernia. It is a tension free technique whereby transabdominally, by the incision of the peritoneum of the inguinal area, we place a polypropylene mesh in the preperitoneal space, followed by the posterior closure of the peritoneum. The technique is based on the Law of Pascal, based on which the variation in pressure produced at a point of a fluid in equilibrium in the gravitational field is entirely transmitted to all the points of that fluid. As a result, intra-abdominal pressure exerted on the hernia area is now used in laparoscopic technique for repairing the hernial defect, the pressure on the mesh being constant at all its points. Figure 16: Pascal s Law. 26

26 The transperitoneal approach offers a number of advantages: Allows visualization of the peritoneal cavity allowing identification of associated pathologies Allows diagnosis of bilateral hernias or femoral hernias and their repair in the same surgical session Enables the solving of strangled hernias by directly establishing the viability of the tissues involved Allows the solving of recurrent hernias working behind the to scar tissues secondary to the open technique Allows the placement of a mesh that covers the entire myopectineal orifice reducing the risk of postoperative relapse It is relatively easy to learn and reproduce especially for surgeons who are already familiar with the abdomen from the perspective of laparoscopy Anatomical Markers As with the TEP technique, it is necessary to identify anatomical markers that need to be viewed in order not to be injured. We will look for the bladder, the ductus deferens with the sperm vessels, the external iliac vascular cord, the medial umbilical ligament and the lateral umbilical ligament containing the lower epigastric vessel. Incision and Arrangement of the Trocars After the incision of the superumbilical skin, insert the Veress needle to establish the pneumoperitoneum, followed by inserting the 10 mm optical trocar. The other 5 mm trocares are located on the medoclavicular line on each side. If we operate on a right inguinal hernia we place the 27

27 right trocar 2 cm above the horizontal line passing through the navel and the left trocar 2 cm below this horizontal line. In the case of bilateral hernias, the trocars will be placed horizontally through the navel. Figure 17: Position of the trocars [12]. After exploring the peritoneal cavity and identifying the anatomical markers we will perform an incision of the parietal peritoneum. We palpate the anterior-superior iliac spine and we start the incision here, initially horizontally towards the median line. At the intersection with the medial umbilical ligament, we advance the incision cranially to ease the preperitoneal dissection. Although this line appears curve in the swollen abdomen, it is projected to the surface on the line between the navel and the anterior-superior iliac spine. After opening the preperitoneal space, we start the proper dissection. We can start from the medial side or from the lateral side, according to our preferences, but always at a distance from the hernial sac. 28

28 If we start on the medial side, the dissection will descend towards the pubic symphysis until it is identified. The Copper ligament shall also be identified. The dissection will be maintained in permanent contact with the peritoneum, a maneuver allowing the identification of all anatomical elements avoiding their lesion. Then, we continue with the lateral dissection of the space, with the identification of the testicular vessels which are detached from the peritoneum and pushed cranially, thus being parietalizated A direct hernia is relatively easy to manage by traction and counter-traction without having contact with the elements of the spermatic cord. In indirect hernias, we will consider that compared to the duct elements, the sac is located laterally and cranially. Ductus deferens is located the most medially, passing below, over the iliac vessels, while the testicular vessels are directed laterally and caudally. After reducing the hernial sac from deep inguinal orifice, continue its dissection until it is fully released and then left laterally and below. The dissection of the preperitoneal space will be mediated so as to exceed the median line by 2 cm to the contralateral side, and below to 4-5 cm from the ilio pubic tract and 2-3 cm below the Cooper ligament. The lateral dissection goes up to the psoas muscle carefully so as not to damage the nerve patches at this level (the genital - femoral nerve, femoral nerve and femoral lateral cutaneous nerve). The dissection is considered complete when we can easily place a 10/15 cm prosthesis, thus covering the entire myopectineal opening and potentially existing hernial orifices at this level. In the case of direct hernias, we will fix the fascia transversalis to the Cooper ligament by means of tacks or transparietal cord to the anterior abdominal wall. For prosthesis, we will use a 15/10 cm polypropylene mesh slightly rounded at the edges to be completely covered with peritoneum. 29

29 The mesh will be fixed in the manner previously described using tacks (resorbable or titanium), or adhesives (biological or synthetic). The closure of the peritoneum is done by continuous suture, application of tacks or adhesives on the peritoneal cross section. This time is extremely important because a peritoneal opening can be the place of some internal hernias and can cause adherence of the intestinal loops to the polypropylene mesh with the ocurrence of some enteric fistulas. The intervention is ended by checking the peritoneal cavity for hemostasis and the evacuation of the gas followed by the suture of the skin. Drainage is an the surgeon s option and is maintained for hours. Complications Associated with Laparoscopic Surgery General complications refer to complications associated with general anesthesia and existing comorbidities. Infectious complications refer to wound infections at the site of trocarization, rarely occurring in laparoscopic hernia, respectively in infections of the mesh due to inappropriate handling or secondary to superinfection of unrecognized and undrained hematomas or seroma. At the time of trocars insertion, hemorrhages may occur through parietal vessel lesions or at the level of epigastric vessel, requiring hemostasis. A hemorrhage at this level is solved by clipping, ligation or cauterization of the vessels involved. Also, in the TAPP technique, lesions of the intra-abdominal viscera may occur upon insertion of the Veress needle or trocars. These lesions must be recognized and solved by suture, sometimes requiring conversion. Subcutaneous emphysema is more commonly associated with 30

30 TEP technique. It does not require extraordinary management, often being resolved in 24 hours. In the case of extensive emphysema, especially in asthenic patients, we can chose the application of some serynge needles at the subcutaneous level, several hours after surgery. The eventrations at the trocar site are possible in the TAPP technique, but can be prevented by suturing the abdominal wall at the insertion site of the 10 mm trocares. Nervous lesions occur when we perform dissection in the pain triangle or secondary to the application of the tacks for the fixation of the mesh in this area. These can be manifested in paraesthesia or chronic pain. The symptomatology is usually solved anti-inflammatory and vitamin B6 therapy [13]. The recurrence in the case of laparoscopic techniques is 1-2%, due to technical errors or the learning curve by the use of small meshes compared to the myopectineal opening or recurrent, occurred in other hernial orifices known during surgery [14 ]. Discussions The treatment of inguinal hernia can be done in many ways. According to the European guidelines, the accepted variants are those with the anterior approach (Lichtenstein and Shouldice technique), respectively those with posterior, endoscopic approach (TEP, TAPP). Numerous studies have attempted to determine which of the two surgical approaches is superior [15,16]. As for anesthesia, the anterior approach can be solved even in local anesthesia or spinal anesthesia, which reduces the cost of the surgery. As related to the pain after surgery, the studies have shown that for the endoscopic approach, much less painkillers are needed, which is associated with the patients reintegration into activity much sooner [17 ]. 31

31 Although the endoscopic approach involves higher costs (equipment, anesthesia), the short hospitalization, reduced need of painkillers and patients quick resumption of the activity compensate these additional costs [18-20]. The endoscopic variants allow the bilateral approach of the hernias and by examining the entire myopectineal orifice and the wide prosthesis of the area, this also solves the possible parietal defects. In terms of complications, wound infections and mesh infections are almost null for the endoscopic approach compared to open techniques. Instead, vascular and visceral complications are more common in laparoscopic surgery. Open techniques have a much shorter learning curve with much better reproducibility than laparoscopic variants. Conclusion After reaching the learning curve and after the surgeon is familiarized with the anatomy of peritoneal space, the laparoscopic approach is the method of choice for the treatment of inguinal hernias. Choosing the appropriate prosthesis (size, porosity, fixation) and covering the entire myopectineal orifice makes the herniated recurrences after this technique identical or less than in the previous approach. As surgeons are increasingly mastering laparoscopic techniques, posterior endoscopic approach becomes the preferred method in the treatment of inguinal hernias, and is associated with minimal pain after surgery, quick recovery of patients and immediate social-economic reintegration. Acknowledgment The current paper was supported by an internal grant of the Iuliu Hatieganu University, awarded to Assistant Professor Florin Zaharie, MD, PhD (No. 4945/2/ ). 32

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