**2.3.2 Laparoscopic repair**

The two laparoscopic techniques that are currently most frequently performed are the transabdominal preperitoneal repair (TAPP) and the total extraperitoneal repair (TEP). Both TAPP and TEP use a mesh in the preperitoneal space as described by Stoppa to replace the visceral sac. These laparoscopic techniques were originally developed for repair of difficult and recurrent inguinal hernias, which were known to have high recurrence rates (Stoppa et al., 1984). Performance of a laparoscopic repair may be technically challenging if the patient has had prior prostatic surgery or lower abdominal radiotherapy. Currently no indications exist in which TAPP is preferred over TEP.

One of the major challenges in learning laparoscopic hernia repair is the relative unfamiliarity of most surgeons to the anterior abdominal wall anatomy from a posterior view. This unfamiliarity is mainly responsible for the steep learning curve, which is associated with an increased incidence of complications. Although peroperative complications are rare in laparoscopic repair, they occur more often early during the learning curve and are more critical. Reported complications include trocar injury to bowel and bladder, vascular injury to the inferior epigastric and femoral vessels, nerve entrapment, transection of vas deferens, and trocar site haemorrhage (Davis & Arregui, 2003). After 250 laparoscopic repairs the recurrence rate is half of the rate of surgeons who have performed fewer repairs (Neumayer et al., 2004). If in future training would not be only incidental but more structurally organised with emphasis on anatomy including a defined proctorship it might be expected that learning curves will be much shorter.

#### **2.3.3 TAPP**

164 Updated Topics in Minimally Invasive Abdominal Surgery

and indirect inguinal hernias. The persistence of a processus vaginalis is often described as a lateral or indirect hernia and a deficient transversalis fascia as a medial or direct hernia. In general clinical distinguishing is often difficult and irrelevant because treatment does not

 **Indirect inguinal hernias** are the most common groin hernias in men and women. The hernia develops at the internal ring laterally to the inferior epigastric artery, in contrast to direct hernias which arise medially to the inferior epigastric vessels. Most indirect inguinal hernias are congenital, even though they may not become symptomatic until later in life (van Wessem et al., 2003). Indirect hernias develop more frequently on the

 **Direct inguinal hernias** occur through the transversalis fascia at (the caudal part of) Hesselbach's triangle, formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus abdominis muscle medially. They occur as a result of a weakness of this part of the transversalis fascia, representing the floor of the inguinal canal. This weakness appears to be most often a congenitally diminished strength of

To be able to compare results most researchers choose to classify hernias by the classification

The two laparoscopic techniques that are currently most frequently performed are the transabdominal preperitoneal repair (TAPP) and the total extraperitoneal repair (TEP). Both TAPP and TEP use a mesh in the preperitoneal space as described by Stoppa to replace the visceral sac. These laparoscopic techniques were originally developed for repair of difficult and recurrent inguinal hernias, which were known to have high recurrence rates (Stoppa et al., 1984). Performance of a laparoscopic repair may be technically challenging if the patient has had prior prostatic surgery or lower abdominal radiotherapy. Currently no indications

One of the major challenges in learning laparoscopic hernia repair is the relative unfamiliarity of most surgeons to the anterior abdominal wall anatomy from a posterior view. This unfamiliarity is mainly responsible for the steep learning curve, which is associated with an increased incidence of complications. Although peroperative complications are rare in laparoscopic repair, they occur more often early during the learning curve and are more critical. Reported complications include trocar injury to bowel and bladder, vascular injury to the inferior epigastric and femoral vessels, nerve entrapment, transection of vas deferens, and trocar site haemorrhage (Davis & Arregui, 2003). After 250 laparoscopic repairs the recurrence rate is half of the rate of surgeons who have performed fewer repairs (Neumayer et al., 2004). If in future training would not be only incidental but more structurally organised with emphasis on anatomy including a

defined proctorship it might be expected that learning curves will be much shorter.

Type 2: Lateral/ indirect hernia with wide internal inguinal ring and normal

right, because the right testicle descends later to the scrotum than the left.

Type 1: Lateral/ indirect hernia with normal internal inguinal ring

differ.

collagen.

of Nyhus (Nyhus, 1993):

 transversalis fascia Type 3a: Medial/ direct hernia

exist in which TAPP is preferred over TEP.

Type 4: Recurrent hernia

**2.3.2 Laparoscopic repair** 

Type 3b: Pantaloon- or combined hernia

The TAPP approach was first described by Arregui and colleagues in 1992 (Arregui et al., 1992). Performing a TAPP, firstly laparoscopic access into the peritoneal cavity is obtained. After identification of the inguinal hernia the peritoneum is incised several centimetres above the peritoneal defect. The peritoneum is incised from the edge of the median umbilical ligament toward the anterior superior iliac spine. Repair of bilateral hernias can be performed through two separate peritoneal incisions or one long transverse incision between the superior iliac spines. Subsequently the preperitoneal avascular space between the posterior and anterior fascia transversalis is dissected to provide visualization of the myopectineal orifice of Fruchaud and size of the abdominal wall defect. In case of an indirect hernia, the cord structures are isolated and dissected free from the surrounding tissues. Simultaneously, the indirect hernia sac is identified on the anterolateral side and adherent to the cord. The cord must be skeletonized with care to minimize trauma to the vas deferens and the spermatic vessels. If the sac is sufficiently small, it can be reduced into the peritoneal cavity. If the hernia sac is large it should be completely dissected and divided beyond the internal ring, and the subsequent peritoneal defect closed with an endoloop suture. The distal end of the transsected sac should be left open to avoid formation of a hydrocèle. When reducing a direct hernia sac, a "pseudosac" may be present, which consists of fascia transversalis that overlies and adheres to the peritoneum and invaginates into the preperitoneal space during the dissection. This layer must be separated from the true hernia sac in order for the peritoneum to be released back fully into the peritoneal cavity. Once the pseudosac is freed, it will typically retract anteriorly into the direct hernia defect.

A large piece of mesh, of at least 15 x 10 cm, is used to cover the myopectineal orifice, including the direct, indirect and femoral hernia spaces. It is important to dissect the preperitoneal space to prevent folding of the edge of the mesh within this space. In addition the mesh should be placed with a slight overlap of the midline to ensure adequate coverage of the entire posterior floor of the groin. The intraperitoneal pressure that is evenly distributed over the large surface of the mesh keeps it in place making fixation of the mesh controversial provided that elimination of fixation does not lead to an increased rate of recurrence. The use of tackers or sutures is associated with increased chronic inguinal pain, use of postoperative narcotic analgesia, hospital length of stay and the development of postoperative urinary retention (Koch et al., 2006; Taylor et al., 2008). Suitable structures for fixation are the contralateral pubic tubercle and the symphysis pubis, Cooper's ligament or the tissue just above it and the posterior rectus sheath and transversalis fascia at least 2 cm above the hernia defect. Fixation is never performed below the iliopubic tract laterally to the internal spermatic vessels, to minimize the chance of damage to the lateral cutaneous nerve of the thigh or the femoral branch of the genitofemoral nerve. Finally the mesh is covered by securing the peritoneal flap back to its original position. The peritoneum should be closed to eliminate the risk of formation of adhesions between the mesh and the intestine. The configuration of the mesh is also important. A slit in the mesh, although attractive in concept, can lead to constriction of the cord structures or allow herniation through the slit.

When using the TAPP technique, in addition to femoral hernias, especially sacless sliding fatty inguinal hernias may be overlooked because of intact peritoneum. Therefore, in cases of clinically diagnosed inguinal hernias, the preperitoneal space should be inspected intraoperatively to avoid unsatisfactory results (Hollinsky & Sandberg, 2010). The main drawback of the TAPP procedure is that it requires entering of the peritoneal cavity with

Laparoscopic Hernia Repair 167

testicle the closure of the processus vaginalis is equally asymmetric, which results in 60% of patent processus vaginalis occurrence on the right side. However only in 25-50% of patients with a patent processus vaginalis a clinically significant hernia will become apparent (Lau et al., 2007; van Veen et al., 2007). Diagnosis of inguinal hernia in children is often based on anamnestic information from the parents or physical examination showing a bulge in the groin with crying or coughing. For timing of elective surgery no evidence is available, but surgical repair is usually performed as soon as possible after diagnosis even if the hernia is asymptomatic. This because of fear of incarceration, although its exact risk has not been studied in paediatric watchful waiting studies. Additionally between 24 and 30 % of patients present with incarcerated inguinal hernia (Moss & Hatch, 1991; Puri et al., 1984). Manual reduction is successful in a majority of patients (Moss & Hatch, 1991; Puri et al., 1984; Stringer et al., 1991). Many paediatric surgeons hospitalize children after successful manual reduction of incarcerated inguinal hernia and repair the hernia within 24-48 hours. The short delay allows the involved tissues to return to their normal texture before surgery. However some surgeons prefer immediate laparoscopy to inspect for vascular compromise

The laparoscopic technique of inguinal hernia repair in children involves a high ligation of the indirect hernia sac without application of a mesh. First the spermatic cord is identified followed by dividing and tracing the sac in the inguinal channel without mobilization of the spermatic cord, with finally ligation of the hernia sac. In girls the surgeons must confirm before ligation that the hernia sac does not contain ovary, fallopian tube, or uterus. In addition to ligation and excision, plication of the floor of the inguinal canal may be necessary when the inguinal ring has been enlarged by repetitive herniation. In paediatric patients surgeons choose for primary repair because of the unknown effect of prosthesis material and because paediatric tissues have greater elasticity making primary repair more straightforward than in the adult population. A debate exists on exploration of the contralateral processus vaginalis during surgery to diagnose and treat asymptomatic contralateral hernia. The incidence of bilateral patent processus vaginalis has been described in literature between 5 and 12% (Manoharan et al., 2005; Miltenburg et al., 1997; Tackett et al., 1999). In open surgery routine contralateral exploration is not recommended, because exploration increases the risk of testicular atrophy and infertility after cord injury. However in laparoscopic hernia repair, evaluation and treatment of the contralateral processus vaginalis is feasible without significant risk of injury to the vas and vessels. Additionally it decreases the need for later contralateral surgery. Femoral hernias in children are rare, occurring in less than 1% of children with groin hernia. They often present as recurrent hernias after inguinal hernia repair, most likely because the surgeon was misled by the findings of a processus vaginalis at the initial surgery and missed the femoral hernia defect.

The term sportsmen hernia describes a condition characterized by chronic groin pain, without a demonstrable defect in the inguinal canal or abdominal wall, mostly observed in athletes. The pain flares with activity and results from chronic, repetitive trauma or stress to the musculotendinous portions of the groin. The exact pathophysiology is unclear and various theories have emerged in literature considering the presences of an occult hernia, a tear or microtears in the transversalis fascia or muscle strain. The theory that posterior weakness in the inguinal wall is the prime cause of groin pain in athletes is supported by the

of bowel, testicular or ovarian tissue with repair of the hernia.

**2.5 Sportsmen hernia** 

increased risk of injury to intra-abdominal organs. Further it requires subsequent incising the peritoneum with eventually peritoneal closure. The TEP was developed to avoid opening the peritoneal cavity with the associated risks.

### **2.3.4 TEP**

The first to describe total extraperitoneal endoscopic repair of a inguinal hernias was Ferzli in 1992 (Ferzli et al., 1992). The procedure is initiated with a subumbilical incision followed by blunt dissection of the subcutaneous layer up to the anterior rectus sheath. The anterior rectus sheath is horizontally incised and with retractors the rectus abdominis muscle is searched and gently moved aside to bring the posterior rectus sheath in sight. The dissection of the preperitoneal space up to the symphysis is continued with a balloon. When using a balloon ('space maker') the thin fibrous layer of the posterior lamina of the fascia transversalis will rupture automatically to expose the 'proper preperitoneal space'. Subsequently a blunt tipped trocar is inserted into the preperitoneal space and a pneumoperitoneum is established. Additional trocars are inserted under direct vision. Further identification and repair of the inguinal hernia is identical to TAPP repair.

#### **2.3.5 Acute repair**

Acute repair of inguinal hernia is necessary in case of incarceration or strangulation. The cumulative probability of hernia getting strangulated after three months is 2.8% (Gallegos et al., 1991). The risks of postoperative complications following emergency surgery are high, and in elderly patients, mortality can be as high as 5% (Nilsson et al., 2007; Primatesta & Goldacre, 1996). Mostly open surgery is performed is case of incarceration to reduce the strangulated content, dissect the hernia sac and repair the abdominal wall defect. In 1993 Watson was the first to report acute laparoscopic reduction of the hernia with resection of the bowel (Watson et al., 1993). This reluctance may be attributable to the technical difficulties encountered in reducing the hernia sac and contents and the increased risk for iatrogenic injuries. The overall rate of complication, recurrence and hospital stay are very close to the rates documented in open repair for incarcerated hernias.

In case of a direct hernia, a releasing incision is made in the anteromedial aspect of the defect to avoid the inferior epigastric vessels. In indirect henias, the vessels are controlled, clipped and transected to facilitate the way for the releasing incision performed anteriorly in the deep (internal) ring at the 12 o'clock position toward the superficial (external) ring facilitating reduction of the incarcerated sac and its contents.

#### **2.4 Laparoscopic repair of inguinal hernia in children**

Laparoscopic repair of indirect hernia is nowadays one of the most frequently executed paediatric surgical procedures. Laparoscopic repair has the same advantages in children as in adults; less pain, faster recovery and better cosmesis. The overall incidence of inguinal hernias in childhood ranges from 0.8% to 4.4% (Bronsther et al., 1972), with predominantly indirect inguinal hernias. Incidence is higher in boys than in girls and in premature infants weighing less than 1000 grams with an incidence between 5 and 30% (Harper et al., 1975; Rajput et al., 1992). Inguinal hernias in children are mostly the result of a patent processus vaginalis because of an arrest of embryologic development. The processus vaginalis closes between the 36th and 40th week of gestation, which explains the increased incidence of hernia in premature infants. Because the descend of the left testis takes place before the right

increased risk of injury to intra-abdominal organs. Further it requires subsequent incising the peritoneum with eventually peritoneal closure. The TEP was developed to avoid

The first to describe total extraperitoneal endoscopic repair of a inguinal hernias was Ferzli in 1992 (Ferzli et al., 1992). The procedure is initiated with a subumbilical incision followed by blunt dissection of the subcutaneous layer up to the anterior rectus sheath. The anterior rectus sheath is horizontally incised and with retractors the rectus abdominis muscle is searched and gently moved aside to bring the posterior rectus sheath in sight. The dissection of the preperitoneal space up to the symphysis is continued with a balloon. When using a balloon ('space maker') the thin fibrous layer of the posterior lamina of the fascia transversalis will rupture automatically to expose the 'proper preperitoneal space'. Subsequently a blunt tipped trocar is inserted into the preperitoneal space and a pneumoperitoneum is established. Additional trocars are inserted under direct vision.

Further identification and repair of the inguinal hernia is identical to TAPP repair.

close to the rates documented in open repair for incarcerated hernias.

facilitating reduction of the incarcerated sac and its contents.

**2.4 Laparoscopic repair of inguinal hernia in children** 

Acute repair of inguinal hernia is necessary in case of incarceration or strangulation. The cumulative probability of hernia getting strangulated after three months is 2.8% (Gallegos et al., 1991). The risks of postoperative complications following emergency surgery are high, and in elderly patients, mortality can be as high as 5% (Nilsson et al., 2007; Primatesta & Goldacre, 1996). Mostly open surgery is performed is case of incarceration to reduce the strangulated content, dissect the hernia sac and repair the abdominal wall defect. In 1993 Watson was the first to report acute laparoscopic reduction of the hernia with resection of the bowel (Watson et al., 1993). This reluctance may be attributable to the technical difficulties encountered in reducing the hernia sac and contents and the increased risk for iatrogenic injuries. The overall rate of complication, recurrence and hospital stay are very

In case of a direct hernia, a releasing incision is made in the anteromedial aspect of the defect to avoid the inferior epigastric vessels. In indirect henias, the vessels are controlled, clipped and transected to facilitate the way for the releasing incision performed anteriorly in the deep (internal) ring at the 12 o'clock position toward the superficial (external) ring

Laparoscopic repair of indirect hernia is nowadays one of the most frequently executed paediatric surgical procedures. Laparoscopic repair has the same advantages in children as in adults; less pain, faster recovery and better cosmesis. The overall incidence of inguinal hernias in childhood ranges from 0.8% to 4.4% (Bronsther et al., 1972), with predominantly indirect inguinal hernias. Incidence is higher in boys than in girls and in premature infants weighing less than 1000 grams with an incidence between 5 and 30% (Harper et al., 1975; Rajput et al., 1992). Inguinal hernias in children are mostly the result of a patent processus vaginalis because of an arrest of embryologic development. The processus vaginalis closes between the 36th and 40th week of gestation, which explains the increased incidence of hernia in premature infants. Because the descend of the left testis takes place before the right

opening the peritoneal cavity with the associated risks.

**2.3.4 TEP** 

**2.3.5 Acute repair** 

testicle the closure of the processus vaginalis is equally asymmetric, which results in 60% of patent processus vaginalis occurrence on the right side. However only in 25-50% of patients with a patent processus vaginalis a clinically significant hernia will become apparent (Lau et al., 2007; van Veen et al., 2007). Diagnosis of inguinal hernia in children is often based on anamnestic information from the parents or physical examination showing a bulge in the groin with crying or coughing. For timing of elective surgery no evidence is available, but surgical repair is usually performed as soon as possible after diagnosis even if the hernia is asymptomatic. This because of fear of incarceration, although its exact risk has not been studied in paediatric watchful waiting studies. Additionally between 24 and 30 % of patients present with incarcerated inguinal hernia (Moss & Hatch, 1991; Puri et al., 1984). Manual reduction is successful in a majority of patients (Moss & Hatch, 1991; Puri et al., 1984; Stringer et al., 1991). Many paediatric surgeons hospitalize children after successful manual reduction of incarcerated inguinal hernia and repair the hernia within 24-48 hours. The short delay allows the involved tissues to return to their normal texture before surgery. However some surgeons prefer immediate laparoscopy to inspect for vascular compromise of bowel, testicular or ovarian tissue with repair of the hernia.

The laparoscopic technique of inguinal hernia repair in children involves a high ligation of the indirect hernia sac without application of a mesh. First the spermatic cord is identified followed by dividing and tracing the sac in the inguinal channel without mobilization of the spermatic cord, with finally ligation of the hernia sac. In girls the surgeons must confirm before ligation that the hernia sac does not contain ovary, fallopian tube, or uterus. In addition to ligation and excision, plication of the floor of the inguinal canal may be necessary when the inguinal ring has been enlarged by repetitive herniation. In paediatric patients surgeons choose for primary repair because of the unknown effect of prosthesis material and because paediatric tissues have greater elasticity making primary repair more straightforward than in the adult population. A debate exists on exploration of the contralateral processus vaginalis during surgery to diagnose and treat asymptomatic contralateral hernia. The incidence of bilateral patent processus vaginalis has been described in literature between 5 and 12% (Manoharan et al., 2005; Miltenburg et al., 1997; Tackett et al., 1999). In open surgery routine contralateral exploration is not recommended, because exploration increases the risk of testicular atrophy and infertility after cord injury. However in laparoscopic hernia repair, evaluation and treatment of the contralateral processus vaginalis is feasible without significant risk of injury to the vas and vessels. Additionally it decreases the need for later contralateral surgery. Femoral hernias in children are rare, occurring in less than 1% of children with groin hernia. They often present as recurrent hernias after inguinal hernia repair, most likely because the surgeon was misled by the findings of a processus vaginalis at the initial surgery and missed the femoral hernia defect.

#### **2.5 Sportsmen hernia**

The term sportsmen hernia describes a condition characterized by chronic groin pain, without a demonstrable defect in the inguinal canal or abdominal wall, mostly observed in athletes. The pain flares with activity and results from chronic, repetitive trauma or stress to the musculotendinous portions of the groin. The exact pathophysiology is unclear and various theories have emerged in literature considering the presences of an occult hernia, a tear or microtears in the transversalis fascia or muscle strain. The theory that posterior weakness in the inguinal wall is the prime cause of groin pain in athletes is supported by the

Laparoscopic Hernia Repair 169

semicircularis, usually located 5 cm caudally to the umbilicus. Cranially to it, the medial aponeuroses of the three lateral muscles give rise to the anterior and posterior layers of the rectus sheath, enveloping the lateral border of the rectus sheath. Cranially to the umbilicus, the muscular part of the transversus abdominis muscle extends more medially than the muscular parts of the oblique muscles. Cranially to the umbilicus the abdominal cavity has an integral muscular cover, except for the linea alba in the midline. Caudally to the umbilicus, the medial borders of the external oblique and transversus abdominis muscles decline laterally, and the medial border of the internal oblique muscle medially. The transversus abdominis muscle is connected to the rectus sheath by its aponeurosis, the fascia of Spigel, which is cutaneously represented by the linea semilunaris (Lange & Kleinrensink,

After establishing a pneumoperitoneum and introducing trocars, laparoscopic ventral hernia repair is started with lysis of intra-abdominal adhesions with caution to prevent bowel injury. After reduction of the hernial content, the hernia sac is commonly left in situ. In doing so seroma formation can occur. The fascial defect is measured and a piece of mesh able to cover the defect with an overlap of at least 3 to 5 cm is cut in shape. The intraabdominal pressure should be lowered to make the abdominal wall more natural shaped and to allow a flat placement of the mesh. The mesh is tension-free implanted and fixated with tackers (every 2 cm) and possibly additional transabdominal sutures (at least every 5 cm). Tackers can be placed in one row or a double row (double-crown technique). Drains are not typically used after laparoscopic hernia repair. Complications than can occur are related to laparoscopy (i.e. bowel injury and subsequent enterotomy), nerve injury by tackers or transabdominal sutures, adhesion formation to the mesh and fixation material, mesh

An incisional hernia develops when the fascial tissue fails to heal at the incision site of a prior laparotomy. Incisional hernia is a common complication and represents about 80% of all ventral hernias. The highest incidence of incisional hernias is observed after midline laparotomy, the most common incision for abdominal surgery. In decreasing order of incidence, incisional hernias are diagnosed after upper midline incisions, lower midline incisions, transverse incisions and subcostal incisions. Incisional hernias are also described

Conditions that impair wound healing make patients susceptible to the development of an incisional hernia, such as wound infection, diabetes mellitus, obesity, immunosuppressive drugs, aneurysm of the abdominal aorta, connective tissue disorders and smoking. Approximately 15-20% of all patients will develop an incisional hernia after midline laparotomy (Hoer et al., 2002; Millbourn et al., 2009; Mudge & Hughes, 1985). The incidence rises up to 35% in patients with an aneurysm of the abdominal aorta (Adye & Luna, 1998; Bevis et al., 2010). Besides patient co-morbidities, technical failure contributes to the development of incisional hernia. After midline laparotomy the fascia should be closed with a non absorbable or slowly-absorbable continuous suture in a suture length to wound length ratio of 4:1 or more to lower the rate of incisional hernia (Hodgson et al., 2000; van 't Riet et

Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).

**3.1 Technique of laparoscopic ventral hernia repair** 

after paramedian, McBurney, Pfannenstiel and flank incisions.

infection and mesh dislocation.

**3.2 Incisional hernia** 

al., 2002).

fact that reinforcement of the posterior wall often resolves the groin pain (Malycha & Lovell, 1992; Paajanen et al., 2004; van Veen et al., 2007; Ziprin et al., 2008).

Sportmen hernia are found almost exclusively in men and only sporadically in women (Hackney, 1993; Moeller, 2007). For patients presenting with groin pain there are numerous other potential causes for groin pain, including hip articulation problems, taking in consideration the complex anatomy and biomechanics of the symphisis region. This makes the sportsmen hernia largely a clinical diagnosis of exclusion by physical examination and usage of radiological imaging. Sportsmen hernia can often be treated conservatively with rest, anti-inflammatiory medication and physiotherapy. However when pain persist after conservative treatment, laparoscopic mesh placement has shown to be a good option.

#### **2.6 Femoral hernia**

Femoral hernias account for 2 to 4% of groin hernias. Femoral hernia present more often in women and account for 23% of groin hernia operations in women, as compared with 1% in men (Dahlstrand et al., 2009). The reason for the higher incidence in women may relate to comparatively less bulky musculature at baseline and weakness of the pelvic floor muscles from previous childbirth. Additionally, the angle of the superior ramus of the pubic bone with the inguinal ligament is less acute in women, explaining for a wider femoral canal.

Femoral hernias frequently present acutely with signs of incarceration and require emergency surgery, with 40% emergency surgery in women and 28% in men. Subsequently bowel resection is required more often than in elective repair, 23% in emergency repair versus 0.6% in elective repair. Additionally, the risk for mortality is 5.4 times increased when compared to elective operations. This highlights the importance of repairing femoral hernias soon after presentation in an elective setting and suggests that there is no indication for watchful waiting in patients with femoral hernias. Strangulated Richter's type femoral hernias occur relatively frequent and carry a significant morbidity and mortality. The diagnosis of such strangulated femoral hernias is invariably delayed because they develop without intestinal obstruction and with minimal local manifestation until the entrapped knuckle of small bowel is gangrenous. A bruit over the femoral vein is an indication that the adjacent femoral hernia is incarcerated or strangulated because the hernia compresses the vein. Both open and laparoscopic approaches have been described for repair of femoral hernia. If a large volume of intra-abdominal contents has protruded into the hernia sac, or if there is bowel in the defect, laparoscopy is the operation of choice. Intra-abdominal contents are best removed by preperitoneal approach. Additionally during laparoscopy the viability of the bowel can be inspected.

#### **3. Hernias of the ventral abdominal wall**

Ventral hernias result from defects in the ventral abdominal wall and are typically classified by etiology and location. They can develop as a result of prior surgery (incisional and trocar site hernia) or at anatomical congenital weak locations (umbilical, epigastric and Spigelian hernia). The abdominal wall exists of five muscles (external oblique, internal oblique, transversus abdominis, rectus abdominis and pyramidal muscles) that protect the viscera. Herniation of the abdominal wall during activity is prevented by the transverse abdominal muscles. In adults the external oblique muscle is aponeurotic up to the level of the umbilicus. The caudal boundary of the posterior layer of the rectus sheath is the linea

fact that reinforcement of the posterior wall often resolves the groin pain (Malycha & Lovell,

Sportmen hernia are found almost exclusively in men and only sporadically in women (Hackney, 1993; Moeller, 2007). For patients presenting with groin pain there are numerous other potential causes for groin pain, including hip articulation problems, taking in consideration the complex anatomy and biomechanics of the symphisis region. This makes the sportsmen hernia largely a clinical diagnosis of exclusion by physical examination and usage of radiological imaging. Sportsmen hernia can often be treated conservatively with rest, anti-inflammatiory medication and physiotherapy. However when pain persist after conservative treatment, laparoscopic mesh placement has shown to be a good option.

Femoral hernias account for 2 to 4% of groin hernias. Femoral hernia present more often in women and account for 23% of groin hernia operations in women, as compared with 1% in men (Dahlstrand et al., 2009). The reason for the higher incidence in women may relate to comparatively less bulky musculature at baseline and weakness of the pelvic floor muscles from previous childbirth. Additionally, the angle of the superior ramus of the pubic bone with the inguinal ligament is less acute in women, explaining for a wider femoral canal. Femoral hernias frequently present acutely with signs of incarceration and require emergency surgery, with 40% emergency surgery in women and 28% in men. Subsequently bowel resection is required more often than in elective repair, 23% in emergency repair versus 0.6% in elective repair. Additionally, the risk for mortality is 5.4 times increased when compared to elective operations. This highlights the importance of repairing femoral hernias soon after presentation in an elective setting and suggests that there is no indication for watchful waiting in patients with femoral hernias. Strangulated Richter's type femoral hernias occur relatively frequent and carry a significant morbidity and mortality. The diagnosis of such strangulated femoral hernias is invariably delayed because they develop without intestinal obstruction and with minimal local manifestation until the entrapped knuckle of small bowel is gangrenous. A bruit over the femoral vein is an indication that the adjacent femoral hernia is incarcerated or strangulated because the hernia compresses the vein. Both open and laparoscopic approaches have been described for repair of femoral hernia. If a large volume of intra-abdominal contents has protruded into the hernia sac, or if there is bowel in the defect, laparoscopy is the operation of choice. Intra-abdominal contents are best removed by preperitoneal approach. Additionally during laparoscopy the viability

Ventral hernias result from defects in the ventral abdominal wall and are typically classified by etiology and location. They can develop as a result of prior surgery (incisional and trocar site hernia) or at anatomical congenital weak locations (umbilical, epigastric and Spigelian hernia). The abdominal wall exists of five muscles (external oblique, internal oblique, transversus abdominis, rectus abdominis and pyramidal muscles) that protect the viscera. Herniation of the abdominal wall during activity is prevented by the transverse abdominal muscles. In adults the external oblique muscle is aponeurotic up to the level of the umbilicus. The caudal boundary of the posterior layer of the rectus sheath is the linea

1992; Paajanen et al., 2004; van Veen et al., 2007; Ziprin et al., 2008).

**2.6 Femoral hernia** 

of the bowel can be inspected.

**3. Hernias of the ventral abdominal wall** 

semicircularis, usually located 5 cm caudally to the umbilicus. Cranially to it, the medial aponeuroses of the three lateral muscles give rise to the anterior and posterior layers of the rectus sheath, enveloping the lateral border of the rectus sheath. Cranially to the umbilicus, the muscular part of the transversus abdominis muscle extends more medially than the muscular parts of the oblique muscles. Cranially to the umbilicus the abdominal cavity has an integral muscular cover, except for the linea alba in the midline. Caudally to the umbilicus, the medial borders of the external oblique and transversus abdominis muscles decline laterally, and the medial border of the internal oblique muscle medially. The transversus abdominis muscle is connected to the rectus sheath by its aponeurosis, the fascia of Spigel, which is cutaneously represented by the linea semilunaris (Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).

#### **3.1 Technique of laparoscopic ventral hernia repair**

After establishing a pneumoperitoneum and introducing trocars, laparoscopic ventral hernia repair is started with lysis of intra-abdominal adhesions with caution to prevent bowel injury. After reduction of the hernial content, the hernia sac is commonly left in situ. In doing so seroma formation can occur. The fascial defect is measured and a piece of mesh able to cover the defect with an overlap of at least 3 to 5 cm is cut in shape. The intraabdominal pressure should be lowered to make the abdominal wall more natural shaped and to allow a flat placement of the mesh. The mesh is tension-free implanted and fixated with tackers (every 2 cm) and possibly additional transabdominal sutures (at least every 5 cm). Tackers can be placed in one row or a double row (double-crown technique). Drains are not typically used after laparoscopic hernia repair. Complications than can occur are related to laparoscopy (i.e. bowel injury and subsequent enterotomy), nerve injury by tackers or transabdominal sutures, adhesion formation to the mesh and fixation material, mesh infection and mesh dislocation.

#### **3.2 Incisional hernia**

An incisional hernia develops when the fascial tissue fails to heal at the incision site of a prior laparotomy. Incisional hernia is a common complication and represents about 80% of all ventral hernias. The highest incidence of incisional hernias is observed after midline laparotomy, the most common incision for abdominal surgery. In decreasing order of incidence, incisional hernias are diagnosed after upper midline incisions, lower midline incisions, transverse incisions and subcostal incisions. Incisional hernias are also described after paramedian, McBurney, Pfannenstiel and flank incisions.

Conditions that impair wound healing make patients susceptible to the development of an incisional hernia, such as wound infection, diabetes mellitus, obesity, immunosuppressive drugs, aneurysm of the abdominal aorta, connective tissue disorders and smoking. Approximately 15-20% of all patients will develop an incisional hernia after midline laparotomy (Hoer et al., 2002; Millbourn et al., 2009; Mudge & Hughes, 1985). The incidence rises up to 35% in patients with an aneurysm of the abdominal aorta (Adye & Luna, 1998; Bevis et al., 2010). Besides patient co-morbidities, technical failure contributes to the development of incisional hernia. After midline laparotomy the fascia should be closed with a non absorbable or slowly-absorbable continuous suture in a suture length to wound length ratio of 4:1 or more to lower the rate of incisional hernia (Hodgson et al., 2000; van 't Riet et al., 2002).

Laparoscopic Hernia Repair 171

fascial defects, known as ''Swiss cheese'' defects, which may be missed during open repair. These small fascial defects are thought to be the major source of incisional hernia recurrence

Trocar site hernias (TSH) have an overall low incidence of less than 1% in adults. The incidence of TSH increases with the size of the used trocar. Almost all TSH develop from trocars of 10 mm or above. Most TSH are located at the umbilical port site, where the largest trocars are used and the fascia is expanded to remove surgical specimen. To prevent TSH the fascia of trocar sites of 10 mm or above should be sutured with a non-absorbable or slowly-absorbable suture, especially in the umbilical area. Co-morbidities as diabetes, smoking and obesity might be risk factors for TSH (Helgstrand et al., 2010). The use of a Veress Needle (instead of an open introduction technique) and a sharp trocar (compared to a conical shaped trocar) are associated with a higher incidence of TSH. In young children the reported incidence of TSH is higher than in adults (5% vs 1%). Herniation of the small sized bowels through trocar ports of 3-5 mm is described, which shows the importance of closing

A congenital umbilical hernia develops when the umbilical scar fails to heal at birth. The incidence of congenital umbilical hernia is 10-30%, with a higher incidence in African American children than in Caucasian children. During the first 1.5 year of life most umbilical hernias close and at the age of 5 almost all children have complete closure of the umbilical ring. Repair should not be considered before an age of 3 years and only in children with large hernias that do not decrease in size or are symptomatic. In the rare case of incarceration, repair is necessary to avoid strangulation (Katz, 2001). Umbilical hernias in adults are an acquired defect in over 90% and are three times more frequently seen in women than in men. The development of an umbilical hernia is associated with obesity, abdominal distension, ascites and pregnancy. In females umbilical hernias are more frequent among multipara and are often easily reducible. Men often present with an incarcerated umbilical hernia, most often containing herniated omentum or preperitoneal fat. Laparoscopic umbilical hernia repair with an onlay patch is a safe and efficacious technique, and compared to open repair has the advantages of a lower rate of wound complications, reduced postoperative pain, shorter hospital stay and a diminished morbidity rate (Lau & Patil, 2003; Toy et al., 1998). Hernia repair in the presence of ascites due to cirrhosis should be considered elective, since emergency repair has an associated morbidity of 70% and mortality of 5% (Telem et al., 2010). Even in patients with mild to

moderate cirrhosis correction can be safely performed (Heniford et al., 2000).

An epigastric hernia is a defect in the linea alba located between the xyphoid process and umbilicus. Epigastric hernias are comparable to umbilical hernias, but smaller in size, often less than 1 cm (Lang et al., 2002). Epigastric hernias are acquired defects with an incidence of 3-5%, three times more frequent in men than in women and mostly diagnosed between 40- 60 years. Associated factors for the development of epigastric hernias are increased intraabdominal pressure and muscle or linea alba weakness. During laparoscopy an epigastric

and therefore identification is important for a successful hernia repair.

**3.3 Trocar site heria** 

**3.4 Umbilical hernia** 

**3.5 Epigastric hernia** 

all trocar port fascias in paediatric patients.

Around 40% of incisional hernias are symptomatic and approximately 1 out of every 3 incisional hernias is repaired in an elective or emergency setting. In the United States, approximately 4 to 5 million laparotomies are performed annually, leading to 400,000 to 500,000 incisional hernias, of which approximately 200,000 repairs are performed (Burger et al., 2004).
