**2.2 Different types of groin hernia**

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 iliac spine and the pubic tubercle of the pubic bone.


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 nowadays the same.

#### **2.3 Inguinal hernia**

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

#### **2.3.1 Classification**

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

Laparoscopic Hernia Repair 165

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

**2.3.3 TAPP** 

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 differ.


To be able to compare results most researchers choose to classify hernias by the classification of Nyhus (Nyhus, 1993):

