Davide Lomanto and Wei Keat Cheah

More than 100 years ago, Bassini in 1887 published his original description of inguinal hernia repair. Many modern modifications had sprung from it, such as the Shouldice repair in 1945 and the Lichtenstein "tensionless" mesh repair. Within less than a decade in the early 1990s, surgeons have not only published their early experiences on laparoscopic intraperitoneal mesh (IPOM) repair of inguinal hernia but also described two major modifications to it- the transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal (TEP) repair. Such is the practice of modern science at a brisk pace.

The addition of laparoscopic repairs only adds to the complexity of choosing the best hernia repair among the numerous types that have been described, but as history shows the best repair is the one that the surgeon has the greatest experience in and thus the lowest recurrence and complication rates. Laparoscopic hernia surgery has maintained its role because of the benefits to patients that are evident when compared to open repairs, as reported in many published randomised controlled trials. Such benefits include less post-operative pain and analgesic consumption, earlier return to normal activities and work, and fewer post-operative problems such as long-term groin pain.

Patient and Trocars Positions (see figure)

General anaesthetic with muscle relaxation is administered. A 1 cm infraumbilical incision is made, the anterior rectus sheath is incised, and the rectus muscle is retracted to expose the posterior rectus sheath. A balloon dissection device (Tyco, Spacemaker,) is inserted over the posterior rectus sheath, guided to the pubic symphysis and inflated, resulting in the separation of the peritoneum from the rectus muscle. This creation of the extraperitoneal space allows for laparoscopic dissection to take place. The balloon device is then removed and replaced with a 10-mm Hasson cannula and a 10 mm angled (30-degrees) laparoscope. Carbon dioxide is insufflated to a pressure not exceeding 12 mmHg. Two 5 mm cannulae are inserted in the midline for placement of laparoscopic graspers.

The first step is to identify key anatomical landmarks (see figure below) such as the pubic bone, the Cooper’s ligament, the spermatic cord, the inferior epigastric vessels (IEV) running superiorly, and the type of hernia in relation to it (direct hernia medial to IEV and indirect hernia lateral to IEV).

The next step is to reduce the hernia sac from the inguinal wall. The indirect hernia sac is reduced and separated from the spermatic cord. Occasionally, a long indirect sac cannot be completely reduced from the deep inguinal ring; in such cases, the sac can be divided and the peritoneal side ligated with a laparoscopic ligature (Endoloop, Ethicon, Johnson & Johnson). In the final step, a rolled polypropylene mesh (8 cm by 12 cm in size) is inserted through the 10-mm port, and with the use of graspers, the mesh is placed horizontally covering the inguinal wall from the midline of the pubis to lateral to the deep inguinal ring. The mesh is then anchored with laparoscopic tacks (Tacker, US Surgical) to Cooper’s ligament to prevent any mesh migration. Tacking is avoided near the iliac vessels or laterally near the ilio-hypogastric nerve, the genitor-femoral nerve, and the lateral femoral-cutaneous nerve of thigh. Occasionally a large piece of mesh (10 cm by 15 cm) is used without anchoring. In all bilateral repairs, two separate pieces of mesh are placed and fixed. At the conclusion, the gas is released and the three wounds are closed with absorbable sutures or glue.