**Laparoscopic Hernia Repair**

Eva Deerenberg, Irene Mulder and Johan Lange

*Erasmus University Medical Centre The Netherlands* 

#### **1. Introduction**

A hernia is a protrusion of abdominal content (preperitoneal fat, omentum or abdominal organs) through an abdominal wall defect. Anatomically the most important features of a hernia are the hernial orifice and the hernia (peritoneal) sac, if present. The hernial orifice is represented by the primary defect in the aponeurotic layer of the abdomen, and the hernial sac by the bulging peritoneum. The neck of the hernial sac is located at the hernial orifice. As the French anatomist Henri Fruchaud (1894-1960) already stated, hernias of the abdominal wall occur in areas where aponeurosis and fascia are lacking the protective support of muscles (Fruchaud, 1953). Most of these weak areas are anatomically present in the abdominal wall congenitally, others may be acquired during life, for example by surgery. The uncovered weak aponeurotic areas are subject to elevated intra-abdominal pressures and give way if they deteriorate or represent anatomic varieties. The common sites of herniation of the abdominal wall are the groin, the umbilicus, the linea alba, the semilunar line of Spigel, the diaphragm and surgical incisions. In addition, more exceptionally obturator hernias and hernias of the triangle of Petit are also encountered. Hernias can broadly be classified into congenital and acquired types. Congenital hernias typically occur at the groin, although they may be observed at other locations such as the umbilicus or diaphragm.

Abdominal wall hernias represent a common issue in general surgical practice. The definitive treatment of all hernias, regardless of their origin or type, is surgical repair. It is suggested that a strategy of watchful waiting rather than surgery can be considered in patients with asymptomatic or minimally symptomatic inguinal and incisional hernia. The risks of delayed surgery are primarily related to the risks of incarceration and strangulation, which necessities emergency surgery. Elective surgical repair should be considered if the hernia is symptomatic, in case of an increased risk for incarceration or if the size of the hernia complicates dressing or activities of daily living. Hernias that are less likely to incarcerate include upper abdominal hernias, hernias with an abdominal wall defect larger than 7-8cm and hernias less than 1 cm in diameter. The likelihood of incarceration decreases as the hernia defect increases in size since it is less likely that intestinal or visceral contents will become caught by a narrow neck of the hernia sac. In large incisional ('giant') hernias more skin problems (ischemia, necrosis and ulcerations) are observed and represent an indication for operation.

The surgical treatment of hernias is already performed since Hellenistic times when Celsus performed hernial sac extirpations. The founder of modern hernia surgery is Bassini from Padova (Italy), who performed the first anatomic hernia groin repair in 1887 (Bassini, 1887).

Laparoscopic Hernia Repair 159

 **Absorbability.** Absorbable materials are less likely to become infected than nonabsorbable materials, and are less harmful to viscera. However the main disadvantage of absorbable meshes is that the resultant scar tissue weakens after the mesh is absorbed and the necessary long-term repair strength is not provided, in contrast with permanent non-absorbable meshes. Partial absorbable meshes are thought to decrease the amount of foreign material while maintaining mechanical strength, but data about the clinical (long-term) performances are not available yet. Total non-absorbable meshes can be

 **Pore size.** Porosity of a mesh is the main determinant of tissue reaction. The space between fibrils influences cellular infiltration, risk of infection, and mesh density and flexibility. Meshes with large pores allow increased tissue ingrowth and are more flexible than meshes with small pores. In a microporous mesh the granulomas around individual fibrils can become confluent which leads to encapsulation of the mesh and makes the mesh inflexible. Microporous meshes are more at risk of becoming infected, as large immune cells cannot infiltrate to phagocytose bacteria. Due to the strong chronic host response, macroporous meshes show good incorporation, but are more likely to give rise to adhesions and erosions than microporous meshes when use intraabdominally. With increasing size of the pores, the chance of bulging of a macroporous

 **Weave.** Multifilament meshes are soft, flexible and resistant to wrinkling. They result in strong integration in the host, but are more susceptible to infection. Monofilament meshes are less susceptible to infection, but have the disadvantage of causing

 **Anti-bacterial of anti-adhesive treatment.** Synthetic meshes with additional coatings (i.e. silver or antiseptics) to reduce the risk of infection or adhesions (i.e. cellulose or collagen layer) have been developed. The anti-adhesive layer functions as a barrier

During laparoscopic hernia repair the mesh can be placed intra- or extraperitoneally. For extraperitoneally placed meshes, commonly used during groin hernia repair, minimal to no fixation is required. This because when intraperitoneal pressure is evenly distributed over the large peritoneal surface from the inside the mesh is kept in place without need for fixation. However, some surgeons fixate the mesh in case of a direct inguinal hernia larger than 2 cm. Fixation is then performed with tackers to the muscles and the periostal fascia of the pubic bone. Care must be taken to avoid the lateral space as all three inguinal nerves are

between the viscera and the mesh and reduces the risk of adhesion formation. Biological meshes made of donor collagen (porcine, bovine or human) are suggested to be used especially in a contaminated or infected environment when closure is required. These new developed collagen meshes are thought to be replaced by the patients own collagen in time (remodelling), with an associated low adhesion formation and low infection risk. They are less suitable for bridging; because due to gradual absorption, the risk of recurrence is high. Unfortunately collagen meshes cannot be introduced through a laparoscopy port yet and more research on outcome and recurrence rates should be done. Finally until now surgeons and hospitals are also reluctant as costs of biological meshes are very high

more stiff and heavy, possibly causing discomfort for the patient.

mesh used for bridging increases.

compared to synthetic meshes.

**1.2 Mesh fixation** 

located within.

significant adhesions when used intra-abdominally.

The results of anatomical hernia repair were a large step forward, however recurrences kept frustrating surgeons since. Over de last decades it has become clear that prosthetic reinforcement by a non-resorbable synthetic polymer mesh is required for most hernia repairs. Abdominal wall hernias can be repaired with mesh reinforcement by open or laparoscopic approach. The first report of the use of a laparoscope in the repair of an abdominal wall hernia was made by Ger in 1982 (Ger, 1982). Bogojavalensky in 1989 was the first to report on the use of a prosthetic mesh during laparoscopic hernia repair (Bogojavalensky, 1989).

The objective of successful hernia repair is achieving a cost-effective repair with a low recurrence rate, minimal operative and acute and chronic postoperative pain with a rapid return to normal activities. Laparoscopic repair has the potential benefits of smaller wounds, with less wound infections and better cosmetic results, and the possibility to perform the procedure in the outpatient clinic. Patients are thought to experience less postoperative discomfort and a faster recovery time. Additional benefit, especially in incisional hernia surgery, is the possibility to diagnose and treat multiple hernias in one procedure. During laparoscopic repair a mesh is placed intraperitoneally which makes contact between the mesh and viscera inevitable. The contact with the viscera can lead to adhesion formation and associated complications like small bowel obstruction, enterocutaneous fistula, infertility and chronic pain. Other possible complications of the laparoscopic approach in general are bowel and bladder injuries, artery laceration, neuralgia and trocar site herniation. During laparoscopic hernia repair it is hardly ever possible to restore functional anatomy of the abdominal wall and manage skin redundancy or the hernia sac.

The risk of recurrence is determined by surgical-technical factors (i.e. mesh use, choice and placement), the experience of the surgeon, the occurrence of a wound infection and patient related factors. Literature shows that recurrence rates are low in experienced hands. Several co-morbidities have been identified that increase the risk of recurrence and wound infection following hernia repair: smoking, diabetes, coronary artery disease, chronic obstructive pulmonary disease (COPD), nutritional status, immunosuppression, chronic corticosteroid use, low serum albumin, obesity and advanced age. A prolonged operative time and the use of an absorbable synthetic mesh are also significant independent predictors of wound infection and associated recurrences.

#### **1.1 Mesh characteristics**

The first prosthetic mesh for hernia repair, introduced in 1900, was a hand-made silver wire filigrees. In the second half of the 20th century nylon, (expanding) PTFE, polypropylene and polyester meshes were introduced. The current large diversity of synthetic polymer and biologic materials available for the reinforcement of hernia repair, without high level evidence for clinical use, complicates the selection of an appropriate prosthesis. The material must be reactive enough to stimulate fibroblast ingrowth, yet inert enough to minimize foreign body reaction, adhesion formation, allergic reaction and to avoid infection. The mesh must have enough strength to prevent early recurrence but enough flexibility to accommodate activity. The mesh should also have optimal laparoscopic handling characteristics. Until now the ideal mesh does not exist and the location of implantation (intra- or extraperitoneally) should be taken into account when choosing a mesh. When choosing a synthetic mesh for laparoscopic hernia repair it is important to consider all characteristics that generate the host response, like absorbability, pore size and weave.

The results of anatomical hernia repair were a large step forward, however recurrences kept frustrating surgeons since. Over de last decades it has become clear that prosthetic reinforcement by a non-resorbable synthetic polymer mesh is required for most hernia repairs. Abdominal wall hernias can be repaired with mesh reinforcement by open or laparoscopic approach. The first report of the use of a laparoscope in the repair of an abdominal wall hernia was made by Ger in 1982 (Ger, 1982). Bogojavalensky in 1989 was the first to report on the use of a prosthetic mesh during laparoscopic hernia repair

The objective of successful hernia repair is achieving a cost-effective repair with a low recurrence rate, minimal operative and acute and chronic postoperative pain with a rapid return to normal activities. Laparoscopic repair has the potential benefits of smaller wounds, with less wound infections and better cosmetic results, and the possibility to perform the procedure in the outpatient clinic. Patients are thought to experience less postoperative discomfort and a faster recovery time. Additional benefit, especially in incisional hernia surgery, is the possibility to diagnose and treat multiple hernias in one procedure. During laparoscopic repair a mesh is placed intraperitoneally which makes contact between the mesh and viscera inevitable. The contact with the viscera can lead to adhesion formation and associated complications like small bowel obstruction, enterocutaneous fistula, infertility and chronic pain. Other possible complications of the laparoscopic approach in general are bowel and bladder injuries, artery laceration, neuralgia and trocar site herniation. During laparoscopic hernia repair it is hardly ever possible to restore functional

anatomy of the abdominal wall and manage skin redundancy or the hernia sac.

The risk of recurrence is determined by surgical-technical factors (i.e. mesh use, choice and placement), the experience of the surgeon, the occurrence of a wound infection and patient related factors. Literature shows that recurrence rates are low in experienced hands. Several co-morbidities have been identified that increase the risk of recurrence and wound infection following hernia repair: smoking, diabetes, coronary artery disease, chronic obstructive pulmonary disease (COPD), nutritional status, immunosuppression, chronic corticosteroid use, low serum albumin, obesity and advanced age. A prolonged operative time and the use of an absorbable synthetic mesh are also significant independent predictors of wound

The first prosthetic mesh for hernia repair, introduced in 1900, was a hand-made silver wire filigrees. In the second half of the 20th century nylon, (expanding) PTFE, polypropylene and polyester meshes were introduced. The current large diversity of synthetic polymer and biologic materials available for the reinforcement of hernia repair, without high level evidence for clinical use, complicates the selection of an appropriate prosthesis. The material must be reactive enough to stimulate fibroblast ingrowth, yet inert enough to minimize foreign body reaction, adhesion formation, allergic reaction and to avoid infection. The mesh must have enough strength to prevent early recurrence but enough flexibility to accommodate activity. The mesh should also have optimal laparoscopic handling characteristics. Until now the ideal mesh does not exist and the location of implantation (intra- or extraperitoneally) should be taken into account when choosing a mesh. When choosing a synthetic mesh for laparoscopic hernia repair it is important to consider all characteristics that generate the host response, like absorbability, pore size and weave.

(Bogojavalensky, 1989).

infection and associated recurrences.

**1.1 Mesh characteristics** 


Biological meshes made of donor collagen (porcine, bovine or human) are suggested to be used especially in a contaminated or infected environment when closure is required. These new developed collagen meshes are thought to be replaced by the patients own collagen in time (remodelling), with an associated low adhesion formation and low infection risk.

They are less suitable for bridging; because due to gradual absorption, the risk of recurrence is high. Unfortunately collagen meshes cannot be introduced through a laparoscopy port yet and more research on outcome and recurrence rates should be done. Finally until now surgeons and hospitals are also reluctant as costs of biological meshes are very high compared to synthetic meshes.

#### **1.2 Mesh fixation**

During laparoscopic hernia repair the mesh can be placed intra- or extraperitoneally. For extraperitoneally placed meshes, commonly used during groin hernia repair, minimal to no fixation is required. This because when intraperitoneal pressure is evenly distributed over the large peritoneal surface from the inside the mesh is kept in place without need for fixation. However, some surgeons fixate the mesh in case of a direct inguinal hernia larger than 2 cm. Fixation is then performed with tackers to the muscles and the periostal fascia of the pubic bone. Care must be taken to avoid the lateral space as all three inguinal nerves are located within.

Laparoscopic Hernia Repair 161

passes through the abdominal wall at the future inguinal canal. After twelve weeks of gestation the ventral peritoneal processus vaginalis follows the gubernaculum, equally piercing the abdominal wall. The processus vaginalis gives rise to the deep and superficial inguinal rings and pushes up the scrotal skin, the subcutaneous layers and the different investing layers of the spermatic cord. The spermatic cord consists of the internal spermatic fascia, cremasteric fascia and external spermatic fascia as continuations of transversalis fascia, internal and external oblique muscles, respectively. Thus, the cranial end of the inguinal canal is the internal or deep inguinal ring, which is a normal defect of the transversalis fascia. Its superior margin is represented by the transversus abdominis arch and the inferior margins are formed by aponeurotic fibers from the iliopubic tract, the inferior epigastric vessels, and the interfoveolar ligament of Hesselbach. The external or superficial inguinal ring is a triangular opening in the aponeurosis of the external oblique muscle. The superior and inferior crura, which form the margins of the ring, are held

In the male within the 'triangle of doom' between the testicular vessels and vas deferens, the external iliac vessels are encountered. They are enveloped by lymphatic and fatty tissue. The deep circumflex iliac artery and vein originate from the external iliac vessels and run parallel to the iliopubic tract (ligament of Thomson), which is the thickened caudal margin of the transversalis fascia. This structure, which extends from the anterior superior iliac spine to the pubic tubercle, dorsally parallels the inguinal ligament. The latter is not visible

The inferior epigastric artery and (two) veins are, especially in the laparoscopic extraperitoneal approach, the hallmark of safe exposure and entering of the 'proper preperitoneal space'. As the external iliac vessels are located within the endo-abdominal fascia, the inferior epigastric vessels pass to the dorsal aspect of the rectus abdominis muscles after perforation of the transversalis fascia, at the lateral boundaries of the rectus abdominis muscles. The frequently occurring accessory obturator artery and vein (corona mortis: 'circle of death'), connecting the obturator and inferior epigastric vessels, cross the superior pubic bone. They are at risk during dissection of the medial part of the pectineal

The genital branch of the genitofemoral nerve innervates the ventral genital skin and the cremaster muscle. After having accompanied the external iliac artery on the psoas muscle, it enters the inguinal canal through the deep inguinal ring, running dorsally to the round ligament of the uterus or the testicular vessels. Laterally to the deep inguinal ring, the lateral femoral cutaneous nerve crosses dorsally to the iliopubic tract, innervating the skin at the lateral side of the thigh. The femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve are observed within the 'triangle of pain', also known as Kathouda's 'quadrant of doom'. The triangle is located between the gonadal vessels and iliopubic tract, at Bogros' space. Bogros' space is located between the transversalis fascia of ventral abdominal wall and the iliopsoas muscles, laterally to the inferior epigastric and external iliac vessels. In this area the application of staples for mesh prosthesis fixation is hazardous. The other nerves from the lumbar plexus (iliophypogastric, ilio-inguinal, obturator and femoral nerves) are only encountered if, inadvertently, dissection is performed between the transversus abdominis and iliopsoas muscles and the transversalis fascia. The nerves encountered in the triangle of pain from medial to lateral are the femoral branch of the genitofemoral nerve, the femoral nerve,

together and reinforced by intercrural fibers.

ligament of Cooper, especially in femoral hernia surgery.

**2.1 Anatomy of the groin** 

from the posterior view.

An intraperitoneally implanted mesh, commonly used in ventral hernia repair, can be fixated using different techniques. Proper fixation of the mesh is important to prevent recurrence, but no consensus about the ideal fixation method exists. The ideal fixation method would guarantee sufficient strength to withstand the pressures generated in the abdomen during coughing and straining. The first used fixation method was represented by stapling, using titanium staples with a penetration depth of 2 to 4.8 mm. These staples could cause chronic pain by compression and twisting of tissue containing nerves. Currently, the most frequently used techniques involve fixation with transabdominal sutures and tackers; titanium helical coils with a maximal tissue penetration depth of 3.8 mm. Fixation with tackers is fast and strong, but complications of adhesions to the tackers and nerve injury and intestinal lesions have been observed. Transabdominal sutures penetrate all layers of the abdominal wall, providing a significant stronger fixation than fixation with tackers only. The disadvantages of transabdominal sutures are the time consuming procedure and the increased risk of chronic postoperative pain by incorporating large bites of tissue.

When fixating a mesh it is important to use an appropriate amount of fixation points, avoiding loosening and incarceration of omentum or bowel loops. Transabdominal sutures should be placed no more than 5 cm apart. An overlap of 3 cm of the fascial defect is sufficient when transabdominal sutures are used. If no sutures are used the minimal overlap of the fascial defect should be 4 to 5 cm. The tackers or staples should be placed every 2 cm. Newly developed are absorbable tackers that absorb within one year. These absorbable tackers may lower the complication rate, but a tack is initially an invasive anchor that can result in nerve damage and postoperative pain. Completely non-invasive mesh fixation, such as with glue sealing, is gaining popularity in inguinal hernia repair, but use of glue in laparoscopic ventral hernia repair is not a common procedure yet. This fixation technique may be promising, but mesh dislocations, when positioned intraperitoneally, are reported.

#### **2. Hernias of the groin region**

The groin is the area of junction of the lower abdomen and the thigh at the myopectineal orifice of Fruchaud. The myopectineal orifice is bounded by the oblique and transversus abdominis muscles cranially, the iliopsoas muscles laterally, the rectus abdominis muscles medially and the pubic pecten caudally. This orifice is the weak spot through which neurovascular, muscular and testicular structures pass the abdominal wall during embryologic development. Protruding through the abdominal wall occurs at this point of the abdominal floor because no muscular covering reinforced by transversalis fascia is present.

The most common symptoms of a groin hernia are heaviness or a dull sense of discomfort in the groin that is most pronounced when the intra-abdominal pressure is raised, for example by straining or lifting. The pain is caused by the contents of the hernia pressing to the tight ring at the neck of the hernia sac. As the intra-abdominal pressure increases, the contents of the hernia are forced into the ring constricting them causing ischemia. Another cause of pain may be from stretching of the ilioinguinal or iliohypogastric nerves hard enter. In case of clinical suspicion of a groin hernia without palpable swelling herniography or MRI have the highest sensitivity and specificity. In daily practice ultrasonography with Valsalva manoeuvre is most often used.

The inguinal area is formed during embryologic development when the gubernaculum develops. This ligament exists between the ovary or testis and labioscrotal swelling and

An intraperitoneally implanted mesh, commonly used in ventral hernia repair, can be fixated using different techniques. Proper fixation of the mesh is important to prevent recurrence, but no consensus about the ideal fixation method exists. The ideal fixation method would guarantee sufficient strength to withstand the pressures generated in the abdomen during coughing and straining. The first used fixation method was represented by stapling, using titanium staples with a penetration depth of 2 to 4.8 mm. These staples could cause chronic pain by compression and twisting of tissue containing nerves. Currently, the most frequently used techniques involve fixation with transabdominal sutures and tackers; titanium helical coils with a maximal tissue penetration depth of 3.8 mm. Fixation with tackers is fast and strong, but complications of adhesions to the tackers and nerve injury and intestinal lesions have been observed. Transabdominal sutures penetrate all layers of the abdominal wall, providing a significant stronger fixation than fixation with tackers only. The disadvantages of transabdominal sutures are the time consuming procedure and the

increased risk of chronic postoperative pain by incorporating large bites of tissue.

**2. Hernias of the groin region** 

manoeuvre is most often used.

When fixating a mesh it is important to use an appropriate amount of fixation points, avoiding loosening and incarceration of omentum or bowel loops. Transabdominal sutures should be placed no more than 5 cm apart. An overlap of 3 cm of the fascial defect is sufficient when transabdominal sutures are used. If no sutures are used the minimal overlap of the fascial defect should be 4 to 5 cm. The tackers or staples should be placed every 2 cm. Newly developed are absorbable tackers that absorb within one year. These absorbable tackers may lower the complication rate, but a tack is initially an invasive anchor that can result in nerve damage and postoperative pain. Completely non-invasive mesh fixation, such as with glue sealing, is gaining popularity in inguinal hernia repair, but use of glue in laparoscopic ventral hernia repair is not a common procedure yet. This fixation technique may be promising, but mesh dislocations, when positioned intraperitoneally, are reported.

The groin is the area of junction of the lower abdomen and the thigh at the myopectineal orifice of Fruchaud. The myopectineal orifice is bounded by the oblique and transversus abdominis muscles cranially, the iliopsoas muscles laterally, the rectus abdominis muscles medially and the pubic pecten caudally. This orifice is the weak spot through which neurovascular, muscular and testicular structures pass the abdominal wall during embryologic development. Protruding through the abdominal wall occurs at this point of the abdominal floor because no muscular covering reinforced by transversalis fascia is present. The most common symptoms of a groin hernia are heaviness or a dull sense of discomfort in the groin that is most pronounced when the intra-abdominal pressure is raised, for example by straining or lifting. The pain is caused by the contents of the hernia pressing to the tight ring at the neck of the hernia sac. As the intra-abdominal pressure increases, the contents of the hernia are forced into the ring constricting them causing ischemia. Another cause of pain may be from stretching of the ilioinguinal or iliohypogastric nerves hard enter. In case of clinical suspicion of a groin hernia without palpable swelling herniography or MRI have the highest sensitivity and specificity. In daily practice ultrasonography with Valsalva

The inguinal area is formed during embryologic development when the gubernaculum develops. This ligament exists between the ovary or testis and labioscrotal swelling and passes through the abdominal wall at the future inguinal canal. After twelve weeks of gestation the ventral peritoneal processus vaginalis follows the gubernaculum, equally piercing the abdominal wall. The processus vaginalis gives rise to the deep and superficial inguinal rings and pushes up the scrotal skin, the subcutaneous layers and the different investing layers of the spermatic cord. The spermatic cord consists of the internal spermatic fascia, cremasteric fascia and external spermatic fascia as continuations of transversalis fascia, internal and external oblique muscles, respectively. Thus, the cranial end of the inguinal canal is the internal or deep inguinal ring, which is a normal defect of the transversalis fascia. Its superior margin is represented by the transversus abdominis arch and the inferior margins are formed by aponeurotic fibers from the iliopubic tract, the inferior epigastric vessels, and the interfoveolar ligament of Hesselbach. The external or superficial inguinal ring is a triangular opening in the aponeurosis of the external oblique muscle. The superior and inferior crura, which form the margins of the ring, are held together and reinforced by intercrural fibers.

#### **2.1 Anatomy of the groin**

In the male within the 'triangle of doom' between the testicular vessels and vas deferens, the external iliac vessels are encountered. They are enveloped by lymphatic and fatty tissue. The deep circumflex iliac artery and vein originate from the external iliac vessels and run parallel to the iliopubic tract (ligament of Thomson), which is the thickened caudal margin of the transversalis fascia. This structure, which extends from the anterior superior iliac spine to the pubic tubercle, dorsally parallels the inguinal ligament. The latter is not visible from the posterior view.

The inferior epigastric artery and (two) veins are, especially in the laparoscopic extraperitoneal approach, the hallmark of safe exposure and entering of the 'proper preperitoneal space'. As the external iliac vessels are located within the endo-abdominal fascia, the inferior epigastric vessels pass to the dorsal aspect of the rectus abdominis muscles after perforation of the transversalis fascia, at the lateral boundaries of the rectus abdominis muscles. The frequently occurring accessory obturator artery and vein (corona mortis: 'circle of death'), connecting the obturator and inferior epigastric vessels, cross the superior pubic bone. They are at risk during dissection of the medial part of the pectineal ligament of Cooper, especially in femoral hernia surgery.

The genital branch of the genitofemoral nerve innervates the ventral genital skin and the cremaster muscle. After having accompanied the external iliac artery on the psoas muscle, it enters the inguinal canal through the deep inguinal ring, running dorsally to the round ligament of the uterus or the testicular vessels. Laterally to the deep inguinal ring, the lateral femoral cutaneous nerve crosses dorsally to the iliopubic tract, innervating the skin at the lateral side of the thigh. The femoral branch of the genitofemoral nerve and the lateral femoral cutaneous nerve are observed within the 'triangle of pain', also known as Kathouda's 'quadrant of doom'. The triangle is located between the gonadal vessels and iliopubic tract, at Bogros' space. Bogros' space is located between the transversalis fascia of ventral abdominal wall and the iliopsoas muscles, laterally to the inferior epigastric and external iliac vessels. In this area the application of staples for mesh prosthesis fixation is hazardous. The other nerves from the lumbar plexus (iliophypogastric, ilio-inguinal, obturator and femoral nerves) are only encountered if, inadvertently, dissection is performed between the transversus abdominis and iliopsoas muscles and the transversalis fascia. The nerves encountered in the triangle of pain from medial to lateral are the femoral branch of the genitofemoral nerve, the femoral nerve,

Laparoscopic Hernia Repair 163

The contents of the inguinal canal differ between male and female. In the male the spermatic cord is surrounded by the cremasteric fascia and cremaster muscle. Within the cord, the spermatic vessels and vas deferens are surrounded by the internal spermatic fascia. The spermatic vessels are the internal spermatic (testicular) artery, the deferential artery and the external spermatic (cremasteric) artery and vein, accompanied by the venous pampniform plexus. Between the internal spermatic and cremasteric fascia, the genital branch of the genitofemoral nerve and the cremasteric vessels are observed. The external spermatic fascia envelops the cord caudally to the superficial inguinal ring. The contents of the inguinal canal in the female include the round ligament of the uterus, the artery of the round ligament of the uterus (Samson's artery), the genital branch of the genitofemoral nerve, the

Groin hernias are divided in inguinal and femoral hernias depending on their position in relation to the inguinal ligament. This structure is formed by the external abdominal oblique aponeurosis and the fascia lata of the thigh. It is located in between the anterior superior

 **Inguinal hernias** are located cranially to the inguinal ligament. The occurrence of inguinal hernias can be explained by the persistence of a processus vaginalis (indirect or lateral hernia), by a deficient fascia transversalis (direct or medial hernia) or by a

**Femoral hernias** occur through the opening located caudally to the ligament inguinal

**Scrotal hernias** are sometimes classified separately but are in fact large indirect

To distinguish an inguinal hernia from a femoral hernia clinically, or an indirect hernia from a direct hernia, is often impossible and is of little importance since the operation is

The inguinal hernia is one of the most frequently occurring hernias with an estimated 20 million hernias repair operations around the world. Estimated incidence rate in the UK is 13 per 10,000 population per year (Primatesta & Goldacre, 1996). Indications for laparoscopic hernia repair are debatable. In case of a primary unilateral hernia an open mesh procedure is currently recommended by the European Hernia Society because of lower recurrence rate, costs and the possibility of local anaesthesia when compared with laparoscopic repair (Simons et al., 2009; Neumayer et al., 2004). From a socio-economic perspective, an endoscopic procedure is probably most cost-effective in patients participating in labour, especially in bilateral hernia. Furthermore chronic postoperative inguinal pain seems to be less generated by laparoscopic repair compared to conventional technique. All patients fit for general surgery without significant contraindications, including extreme age or significant cardiac, pulmonary or systemic illness, should be offered the option of a

To date, there is a lack of consensus among general surgeons and hernia specialists on classification systems for inguinal hernias. The traditional system classifies them into direct

inguinal hernias with a hernia sac reaching into the scrotum.

ilio-inguinal nerve and lymphatics.

**2.2 Different types of groin hernia** 

combination of both.

nowadays the same.

**2.3 Inguinal hernia** 

**2.3.1 Classification** 

and medially to the femoral vein.

laparoscopic hernia repair (Simons et al., 2009).

iliac spine and the pubic tubercle of the pubic bone.

the cutaneous branch of the femoral nerve and the lateral femoral cutaneous nerve. The anatomic landmarks and structures of importance are illustrated in the RISE (Rotterdam Institute of Surgical Endoscopy)-circle, figure 1 (Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).

#### **Ventromedial quadrant (direct hernia):** Base; iliopubic tract (of Thomson)(1) Conjoint tendon(2) Transeversalis fascia (caudal part of Hesselbach's triangle)(3) Interfoveolar ligament (of Hesselbach)(4) Branches of inferior epigastric vessels **Dorsomedial quadrant (femoral hernia at femoral canal/lacuna vasorum):**  Pectineal ligament (of Cooper)(5) Lacunar ligament (of Gimbernat)(6) Bladder Corona mortis External iliac vein

Prevesical space (of Retzius)

#### **Ventrolateral quadrant (indirect hernia):**  Deep inguinal ring Interfoveolar ligament (of Hesselbach) Transversus abdominis muscle(7)

#### **Dorsolateral quadrant (Kathouda's quadrant of doom):**

Nerves of triangle of pain: Femoral branch of genitofemoral nerve(8) Femoral nerve(9) Cutaneous branch of femoral nerve(10) Lateral femoral cutaneous nerve (11) Testicular vessels Iliopectineal arch (ligament) Vas deferens(12) or round ligament of uterus

Fig. 1. RISE (Rotterdam Institute of Surgical Endoscopy)-circle. Anatomic landmarks and structures of importance in inguinal hernia repair (Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002).

the cutaneous branch of the femoral nerve and the lateral femoral cutaneous nerve. The anatomic landmarks and structures of importance are illustrated in the RISE (Rotterdam Institute of Surgical Endoscopy)-circle, figure 1 (Lange & Kleinrensink, Surgical Anatomy of

**Ventrolateral quadrant (indirect hernia):** 

**Dorsolateral quadrant (Kathouda's quadrant of** 

Femoral branch of genitofemoral nerve(8)

Vas deferens(12) or round ligament of uterus

Cutaneous branch of femoral nerve(10) Lateral femoral cutaneous nerve (11)

Interfoveolar ligament (of Hesselbach) Transversus abdominis muscle(7)

Deep inguinal ring

Nerves of triangle of pain:

Iliopectineal arch (ligament)

Femoral nerve(9)

Testicular vessels

**doom):** 

Fig. 1. RISE (Rotterdam Institute of Surgical Endoscopy)-circle. Anatomic landmarks and structures of importance in inguinal hernia repair (Lange & Kleinrensink, Surgical Anatomy

the Abdomen, Elsevier gezondheidszorg, 2002).

**Ventromedial quadrant (direct hernia):** Base; iliopubic tract (of Thomson)(1)

Interfoveolar ligament (of Hesselbach)(4) Branches of inferior epigastric vessels

**Dorsomedial quadrant (femoral hernia at** 

of the Abdomen, Elsevier gezondheidszorg, 2002).

Transeversalis fascia (caudal part of

**femoral canal/lacuna vasorum):**  Pectineal ligament (of Cooper)(5) Lacunar ligament (of Gimbernat)(6)

Prevesical space (of Retzius)

Conjoint tendon(2)

Bladder Corona mortis External iliac vein

Hesselbach's triangle)(3)

The contents of the inguinal canal differ between male and female. In the male the spermatic cord is surrounded by the cremasteric fascia and cremaster muscle. Within the cord, the spermatic vessels and vas deferens are surrounded by the internal spermatic fascia. The spermatic vessels are the internal spermatic (testicular) artery, the deferential artery and the external spermatic (cremasteric) artery and vein, accompanied by the venous pampniform plexus. Between the internal spermatic and cremasteric fascia, the genital branch of the genitofemoral nerve and the cremasteric vessels are observed. The external spermatic fascia envelops the cord caudally to the superficial inguinal ring. The contents of the inguinal canal in the female include the round ligament of the uterus, the artery of the round ligament of the uterus (Samson's artery), the genital branch of the genitofemoral nerve, the ilio-inguinal nerve and lymphatics.
