Robotic Inguinal Hernia Repair

Background Information:

Inguinal hernias occur when abdominal contents herniate through the inguinal canal (indirect) or Hesselbach's triangle (direct) or both (pantaloon hernia). Direct inguinal hernias occur secondary to increased intraabdominal pressure and indirect hernias resulting from patent processus vaginalis in males or canal of Nuck in females (an extension of the peritoneum that closes during normal development). Inguinal hernias may contain various contents but commonly contain intraperitoneal fat, small bowel, or cord lipoma. An inguinal hernia containing the appendix is termed an Amyand’s hernia. A sliding hernia occurs when a retroperitoneal organ makes up part of the hernia sac. Asymptomatic inguinal hernias often become symptomatic over time. Inguinal hernias are repaired using open or minimally invasive (laparoscopic or robotic) techniques.

The minimally invasive repair is achieved through two different approaches: the transabdominal preperitoneal (TAPP) approach, and the totally extraperitoneal (TEP) approach. The proposed advantages of the minimally invasive approach is the use of larger mesh covering the entire myopectineal orifice, and the ability to easily treat bilateral hernias and recurrent hernias that have been treated with an open technique. The TAPP approach may be performed robotically which, for the robotically experienced surgeon, can provide additional dexterity and three-dimensional optics to aid in the procedure. 

Indications:

Symptomatic inguinal hernias should be electively repaired. Incarcerated hernias should be repaired emergently. Minimally invasive repairs are indicated if bilateral hernias are present, if a hernia has recurred following the open approach, or for surgeon preference.

Procedure Description:

TAPP

Three port sites are placed, one at the umbilicus, and two lateral to the rectus sheath at the level of the umbilicus. The trocars are advanced into the peritoneal cavity and pneumoperitoneum is established. Next, the parietal peritoneum is incised, and a plane is created within the preperitoneal plane and dissection is continued down to Cooper’s ligament and the iliopubic tract. The hernia sac is then reduced. If an indirect hernia is present, the hernia sac is reduced and dissected from the cord structures (or round ligament in women). Once the dissection of the preperitoneal plane is complete, mesh is placed in the preperitoneal plane covering the entire myopectineal orifice. The mesh is then sutured or tacked to the abdominal wall. The peritoneum is then suture repaired to correct the defect. 

TEP

Three port sites are required, one at the umbilicus, and two extending caudally in the midline. Prior to trocars being placed, at the infraumbilical location, dissection is carried down to the posterior rectus sheath. A balloon is introduced and inflated into retrorectus space between the posterior rectus sheath and the rectus muscle. As this plane is dissected by the inflation of the balloon, caudal to the arcuate line, the preperitoneal space is entered. Balloon dissection continues to the pubic symphysis. The remaining procedure mirrors the TAPP procedure taking care not to enter the peritoneum. 

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Key Anatomy:

Subcutaneous tissue 

• Camper's fascia
• Scarpa's fascia

Abdominal wall:

• Rectus abdominis
• Anterior rectus sheath
• Posterior rectus sheath
• Arcuate line
• External oblique aponeurosis
• Internal oblique muscle
• Hesselbach's triangle (direct hernia space)

• ~Lateral border: inferior epigastric vessels
• ~Inferior border: inguinal ligament
• ~Medial border: lateral border of rectus abdominis muscle

• Adminiculum of linea albae
• Myopectineal orifice 
• Median umbilical ligament

• Contains obliterated urachus

• Medial umbilical ligaments

• ~Contains obliterated umbilical arteries

• Lateral umbilical folds

• ~Contains inferior epigastric vessels

Inguinal anatomy

• Iliopubic tract
• Deep (internal) inguinal ring
• Vas deferens
• Cooper's ligament
• Lacunar ligament

Nerves

• Ilioinguinal nerve
• Genital branch of the genitofemoral nerve
• Iliohypogastric nerve
• Lateral femoral cutaneous nerve

Vasculature

• External iliac artery/vein
• Inferior epigastric artery
• Corona mortis
• Testicular artery

Bony landmarks

• Anterior superior iliac spine (ASIS)
• Pubic tubercle 

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Risks:

General surgical risks:

• Bleeding
• Infection

Risks with laparoscopic/robotic repair

• Hernia recurrence (varies widely based on study, up to 10%ⁱ)
• Port site hernia (0.5%²)
• Persistent pain (18% vs 25% for open³)
• Mesh infections (rare)

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