Crucial anatomy and technical cues for laparoscopic transabdominal preperitoneal repair: Advanced manipulation for groin hernias in adults

Abstract

Groin hernias include indirect inguinal, direct inguinal, and femoral hernias. Obturator and supravesical hernias appear very close to the groin. High-quality repairs are required for groin hernias. The concept of “tension-free repair” is generally accepted, and surgical repairs with mesh are categorized as “hernioplasties”. Surgeons should have good knowledge of the relevant anatomy. Physicians generally focus on the preperitoneal space, myopectineal orifice, topographic nerves, and regional vessels. Currently, laparoscopic surgery has therapeutic potential in the surgical setting for hernioplasty, with laparoscopic transabdominal preperitoneal (TAPP) repair appearing to be a powerful tool for use in adult hernia patients. TAPP offers the advantages of accurate diagnoses, repair of bilateral and recurrent hernias, less postoperative pain, early recovery allowing work and activities, tension-free repair of the preperitoneal (posterior) space, ability to cover obturator hernias, and avoidance of potential injury to the spermatic cord. The disadvantages of TAPP are the need for general anesthesia, adhering to a learning curve, higher cost, unexpected complications related to abdominal organs, adhesion to the mesh, unexpected injuries to vessels, prolonged operative time, and as-yet-unknown long-term outcomes. Both technical skill and anatomical familiarity are important for safe, reliable surgery. With increasing awareness of the importance of anatomy during TAPP repair, we address the skills and pitfalls during laparoscopic TAPP repair in adult patients using illustrations and schemas. We also address debatable points on this subject.

Robotische Hernienchirurgie I

“…1 /11), meistens unter der Fascia iliaca (Abb. 1 /12); die Fascia iliaca und die Nerven müssen bei der Präparation unbeschädigt bleiben [ 9 , 14 , 15 ].…”

Robotic hernia surgery I. English version

“…Fig. 1/12), which protects them; the iliac fascia and the above-mentioned nerves must remain undamaged during dissection [9,14,15].…”

“…1 /11), are generally to be found under the iliac fascia (Fig. 1 /12), which protects them; the iliac fascia and the above-mentioned nerves must remain undamaged during dissection [ 9 , 14 , 15 ].…”

The Preperitoneal Space in Hernia Repair

“…When dissecting laterally, in order to find the peritoneal sac (and reduce the hernia), this extension of the urogenital fascia has to be transected. This step of dissection ( Figure 5B ) is referred to as a switch between a superficial parietal layer (anterior sub-peritoneal fascia) and a deep visceral layer (posterior sub-peritoneal fascia) by some ( 22 ), whereas Stoppa procedure described a “spermatic sheath,” a triangular fibrocellular lamella sheathing the spermatic cords and gonadal vessels in males and a similar genital sheath in females ( 23 ). This extension of the urogenital fascia divides the space of Bogros into a cleavable space between the peritoneum and genital sheath without notable vasculature and a space between the TF and the genital sheath containing nerves and blood vessels.…”