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Lap Hernia Repair

Lap Hernia Repair

The most comprehensive, structured curriculum and hands-on training for laparoscopic Hernia Repair

For patients with recurrent inguinal hernia, or bilateral inguinal hernia, or for women, laparoscopic repair offers significant advantages over open techniques with regard to recurrence risk, pain, and recovery. For unilateral first-time hernias, either laparoscopic or open repair with mesh can offer excellent results. The major drawback of laparoscopy is that the technique requires a significant number of cases to master.

INTRODUCTION:

A hernia happens when an organ (e.g. the intestines) pushes through an opening in the muscle that keeps it in place (e.g. the abdominal wall). The most common type is an inguinal hernia, which occurs when the intestines push through the inguinal canal in the lower abdomen. Left untreated, a hernia can progress to become more painful and dangerous, even become life-threatening.

TECHNIQUE:

  • Diagnosis of a hernia is relatively simple; it can be performed through a physical exam, barium X-ray, or endoscopy.Treatment can vary from simple dietary changes and prescription medication (often applicable only for a hiatal hernia where the stomach protrudes through the diaphragm) to open or laparoscopic surgery.
  • However, when non-invasive methods do not work (e.g. when a person has an inguinal hernia), surgery is the only way to correct it. When caught early, doctors often recommend laparoscopic hernia repair because it is minimally invasive and has a shorter recovery time. However, this type of treatment is not suitable for a hernia in advanced stages.


  • Three trocars are used for a TAPP repair: one 11-mm subumbilical port and two 5-mm ports placed in the same transverse plane as the subumbilical port, approximately 5-7 cm away. The 5-mm ports are just cephalad and medial to the anterior superior iliac spines.
  • A 10-mm, 30°-angle laparoscope should be used to inspect the groin anatomy. The inferior epigastric vessels, the spermatic vessels, and the vas deferens should be identified. These three structures form the so-called “Mercedes-Benz” sign.
  • The peritoneum is incised several centimeters above the myopectineal orifice, from the edge of the medial umbilical ligament laterally toward the anterior superior iliac spine. Working inferiorly, in a motion similar to opening a piece of pita bread, the surgeon should bluntly dissect the peritoneum off the transversus abdominus and transversalis fascia until the pubis, Cooper’s ligament, and iliopubic tract are seen.


  • An indirect hernia sac is usually found on the anterolateral side of the cord. When dissecting the sac, it is important to minimize trauma to the vas deferens and the spermatic vessels. If the sac is sufficiently small, it should be completely dissected free from the cord and returned to the peritoneal cavity.
  • The distal end of the transected sac should be left open to avoid formation of a hydrocele. The vas deferens and spermatic vessels are isolated and dissected free from the surrounding tissues circumferentially, creating a window inferiorly, to allow for passage of the lower tail of the mesh.
  • For indirect hernias, we use a 12-cm × 16-cm flat mesh with rounded corners and slit medially so that the tails wrap around the cord structures (Fig. 4). The slit in the mesh allows it to lie flat in the preperitoneal space and avoids indirect recurrence. The tails are fixed to Cooper’s ligament with two tacks, avoiding the accessory obturator vein which courses in the region