Perhaps the most controversial of new laparoscopic operations is the repair of the inguinal hernia. The

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1 JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 6, 1992 Mary Ann Liebert, Inc., Publishers Extraperitoneal Endoscopie Inguinal Hernia Repair GEORGE S. FERZLI, M.D., F.A.C.S., AZIZ MASSAD, M.D., and PETER ALBERT, M.D., F.A.C.S. ABSTRACT The endoscopie extraperitoneal hernioplasty as reported in this study is a similar repair to that achieved by the conventional preperitoneal repair as described by Stoffa, Nyhus, and Rignault. However, this new repair is completed via a totally extraperitoneal approach. Thus, it eliminates all early and late complications related to the violation of the peritoneal cavity as proposed by other intraperitoneal laparoscopic approaches to hernia repair. This report demonstrates the safety and feasibility of this procedure while offering the patient the advantages of a minimally invasive surgical procedure which can be performed under regional anesthesia. INTRODUCTION Perhaps the most controversial of new laparoscopic operations is the repair of the inguinal hernia. The advantages of the laparoscopic approach are that bilateral herniorrhaphy can be performed through the same three operative sites, with less postoperative pain, and quicker return to full activity. Unfortunately, the laparoscopic method cannot be used without general anesthesia and the long term results are not as yet known. The authors herein describe a total extraperitoneal approach for hernia repair, the technique, and early results. MATERIALS AND METHODS The patient is placed in supine position after general endotracheal anesthesia is induced. A Foley catheter is inserted and the abdomen and perineum are prepped and draped. A small incision is made in the inferior aspect of the umbilicus. Dissection is then carried through the subcutaneous tissue to the fascial level which is incised. Sutures are placed on either side of the midline in the fascia which will later be used to secure the Hasson trocar. The dissection which ensues will be totally preperitoneal, leaving the peritoneal cavity and its contents undisturbed. Blunt finger dissection is utilized to dissect the fibrous attachments between the rectus muscles and the peritoneum. This maneuver will create a small preperitoneal cavity. A 10 mm Hasson cannula is introduced into this cavity and anchored under tension to the previously placed fascial stay sutures. The C02 insufflation tubing is then attached to the cannula. An insufflation pressure of 8 mmhg is maintained. A 10 Department of Laparoendoscopic Surgery, Staten Island University Hospital, Staten Island, NY. 281

2 FERZLI ET AL. FIG. 1. Trocar placement anterior view. mm zero degree operative scope with a 5 mm working channel is introduced into the trocar. Blunt probe dissection is then used to further develop the preperitoneal space in the midline down to the level of the pubic symphysis. From the midline, further dissection is carried laterally on each side to further develop this cavity. Under direct vision, two other trocars are placed in the midline (Fig. 1). Additional trocars can be placed, if needed, lateral to the rectus muscles below the linea semicircularis. Once this has been placed, the operative scope is removed and replaced with a straight zero degree 10 mm scope. Fine dissections and scissors are now used to dissect the anatomy on the side of the hernia. Complete muscle relaxation and degree Trendelenburg position will aid in the dissection. The dissection is now first begun at the level of the pubis, then along Cooper's ligament to the femoral canal, after which the epigastric vessels are seen, along with the internal ring and spermatic cord structures (Fig. 2). The dissection must be meticulously performed using the standard anatomical boundaries. This dissection is now continued laterally to identify the iliopubic tract. The type of defect is readily visible. A femoral defect is seen medial to the femoral vessels, a direct defect is seen medial to the epigastric vessels, and an indirect defect is seen lateral to the epigastric vessels (Fig. 3). In the case of an indirect hernia, the sac is dissected off the cord structures. This dissection can be facilitated by placing the scope in the middle cannula FIG. 2. Trocar placement lateral view, note the preperitoneal position. 282

3 ENDOSCOPIC HERNIA REPAIR FIG. 3. Anatomy depicting the location of the three hernia defects; (d) = direct, (f) = femoral, (i) = indirect. or by using a 30 degree 10 mm scope. The sac is opened to ascertain that no intraabdominal contents are present within its lumen. The sac is then ligated using endoloop ligatures, excised, and submitted for pathologic examination. If the hernia is bilateral, the opposite side is then dissected in a similar fashion. A polypropylene mesh, previously cut and measured at the skin level, is then introduced into the preperitoneal cavity. It is positioned to cover the hernia defect described in Fig. 4. The prosthetic mesh is usually split to allow the cord to pass through, but it can also be inserted after parietalization of the cord. It is then secured in place using the hernia stapler, thereby totally avoiding any injury to the vascular and spermatic cord structures. Trocars are removed under direct vision and the fasical defect is sutured closed. A sterile dressing is applied. Prophylactic antibiotics are used before, during, and after the procedure. FIG. 4. Mesh placement covering all three potential anatomical defect areas. 283

4 FERZLI ET AL. DISCUSSION The transabdominal management of inguinal hernias was popularized by Tait in 1891.' However, laparoscopic management of the inguinal hernias was first suggested by Ger in Using a specially designed staple called "Herniastat," Ger reapproximated the internal ring opening.2 Later that year, Popp reported a case of endoscopie inguinal hernia repair in a female using polypropylene mesh which was inserted into the defect after incising the overlying peritoneum.3 In the same year, Schultz presented his early results in 20 patients using an intraperitoneal approach to identify the defects while obliterating the defect with two plugs and a patch of polypropylene mesh and then reapproximating the edges of the peritoneum.4 In an 11-month follow up there was one recurrence. Using the same technique, he later reported on his first 50 patients with no complications but two early and six late recurrences of the hernias.5 Recently, Schultz reported a 2-year follow up on 135 patients with three recurrences in large scrotal hernias with mesh fixation. Patients returned to unrestricted activity in an average of 4.7 days and 32% of his patients required no postoperative pain medication.6 Other intraperitoneal techniques using prosthetic material were described. Corbitt used a polypropylene plug or patch graft combined with high ligation of the sac using an Endo GIA stapler.7 He reported one recurrence in 50 patients. Popp8'9 presented a transcutaneous aqua dissection to allow placement of the prosthetic covering. Toy and Smoot described their technique in 10 patients using an expanded PTFE patch over the defect in an intraperitoneal position.10 The intraabdominal preperitoneal mesh placement is now the most popular laparoscopic hernia repair being performed. In all of the previously described techniques, the peritoneal cavity is entered, risking possible associated complications. The peritoneal coverage over the mesh is technically difficult with multiple tears likely to be present in the closure. The mesh plug in the inguinal canal will form a hard uncomfortable mass which could infiltrate into the scrotum and possibly erode through the skin. In addition, leaving the hernia sac behind may promote hydrocele formation. Long term fate of intraperitoneal prosthetic material is still unknown. Erosion into adjacent structures, formation of adhesions, and foreign body infection must be a concern. Mora et al showed that biomaterials placed intraperitoneally and near the gastrointestinal tract can become infected with bowel organisms, most likely from translocation. ' ' Moreover, the optimal prosthetic material has not yet been discovered. Therefore, an extraperitoneal approach to groin hernias seems to be more advantageous due to the avoidance of Veress needle-associated complications (bowel and vessel injuries), and the smaller likelihood of adhesion formation. Hypercarbia and hypothermia associated with pneumoperitoneum are also avoided and there is less ileus formation and no postoperative shoulder pain. Moreover, the extraperitoneal approach is well described by Stoppa, who reported a 2.5% recurrence rate in the most difficult recurrent hernias12; and Nyhus, who reported a 1.7% recurrence rate for repair of recurrent groin hernias.1 Even though the use of prosthetic material in primary repairs remains controversial, its recent use was popularized by Lichtenstein and others.14"16 With the advent of new technology in laparoscopic instrumentation, progress has made it possible to accomplish the extraperitoneal (preperitoneal) approach endoscopically through three small midline incisions. The anatomy is well delineated through this approach.17 CLINICAL EXPERIENCE In one of the authors' surgical practice (G.F.), using the originally cited laparoscopic technique, a high failure rate in his initial 30 patient group. The following represents the patient profile patients undergoing 31 herniorrhaphies using the extraperitoneal endoscopie hernia repair: there was in the first 25 (1) All 25 patients had their procedure performed on an outpatient basis. (2) All returned to full activity within 72 h of their surgical repair. (3) The maximum pain medication needed to control postoperative pain was 0-6 tablets of Tylenol #3 and no patients required Demerol or Percocet. (4) Polypropylene mesh was used in all of the cases. It was preferred to PTFE because of the ability to see through this material. 284

5 ENDOSCOPIC HERNIA REPAIR (5) The patient age profile was between years of age. (6) The average operative time was 90 min with the first few cases taking as long as 3'/2 h and subsequent cases having an operative time of less than 45 min. (7) All patients had general anesthesia. (8) 6 patients had bilateral hernia repair and 19 had a unilateral repair. (9) Of the 31 hernia repairs; eight were indirect (with one sliding hernia) and 22 were direct with one patient having a femoral hernia. (10) Three patients had prior surgical procedures; two with appendectomies and one with an umbilical hernia repair. (11) One patient had to be converted into an open repair due to a tear in the peritoneal cavity. The postoperative follow up is still too soon to assess the recurrence rate since it is less than 6 months; however, thus far, there were no recurrences. (12) There were no morbidities or mortalities. CONCLUSION A technique of endoscopie preperitoneal hernia repair with mesh is presented. It is not a new repair but an old one via a new route that is better tolerated by the patient. This approach avoids the peritoneal cavity with its possible inherent intraabdominal complications. It offers the patient a rapid return to full activity with minimal discomfort that has not been accomplished with the standard hernia repair. This is best seen in the patient with bilateral hernia repair that can be approached through the same three midline trocar sites. This approach also avoids the risks of neuralgia and testicular atrophy seen in the conventional open hernia repairs. The authors recommend this approach for bilateral hernias, recurrent hernias, and in certain primary repairs. It can be performed on an outpatient ambulatory basis and attempts to perform this approach under regional anesthesia are currently being made. REFERENCES 1. Tait L: A discussion of treatment of hernia by medial abdominal section. Br Med J (Clin Res) 1891:2: GerR, Monroe R, DuvierR, et al: Management of indirect inguinal hernia by laparoscopic closure of the neck of the sac. Am J Surg 1990;159: Popp LW: Endoscopie patch repair of inguinal hernia in a female patient. Surg Endose 1990;4: Schultz L, Graber J, Pietrafitta J, Hickok D: Laser laparoscopic herniorrhaphy: A Clinical Trial Preliminary Results. J Laparoendosc Surg 1990;1(1): Schultz L, Graber J, Pietrafitta J, Hickok D: Laser laparoscopic inguinal herniorrhaphy. Lasers Surg Med 199I;(suppl. 3): Schultz L: Comments on laparoscopic herniorrhaphy. Surgery Alert 1992; Corbitt JD: Laparoscopic herniorrhaphy. South Med J 1991 ;84(9): Popp LW: Endoscopie hernioplasty: Transcutaneous aqua dissection of the hernia sac and preperitoneal prosthetic covering of the abdominal wall defect. Chirurgie 1991;62(4): Popp LW: Improvement in endoscopie hernioplasty: Transcutaneous aqua dissection of the musculofascial defect and preperitoneal endoscopie repair. J Laparoendosc Surg 1991; 1: Toy FK, Smoot RT: Laparoscopic hernioplasty. Surgical Laparosc Endose 1991; 1(3): Mora EM, Cardona MA, Simmons RL: Enteric bacteria and ingested inert particle translocation to intraperitoneal prosthetic material. Arch Surg 1991; 126: Stoppa R, Cheuret JP: Hernia of the Abdominal Wall. New York, NY: Springer Verlag; 1987: Nyhus LM: The recurrent groin hernia therapeutic solutions. World J Surg 1989; 13:

6 FERZLI ET AL. 14. Lichenstein IL, Schulman AG, Amid PK, et al: The tension free hernioplasty Am J Surg 1989;157: Rignault DP: Preperitoneal prosthetic inguinal herniorrhaphy through a pfannenstiel approach. Surg Gynecol Obstet 1986:162: Stoppa RE, Warlaumont CR: The preperitoneal approach and prosthetic repair of groin hernia. In: Hernia, 3rd Ed, Nyhus LS, Condon RE (Eds). Phila, PA: J.B. Lippincott: 1989: Spaw AL. Ennis BW, Spaw LP: Laparoscopic hernia repair, the anatomic basis. J Laparoendosc Surg 1991 ; 1 (5):269. Address reprint requests to: George S. Ferzli, M.D., F.A.C.S. Department of Laparoendoscopic Surgery Staten Island University Hospital Staten Island, NY