What is Laparoscopic Inguinal Hernia Surgery?

Hernias that occur in the groin are known as inguinal hernias. These are characterized by small balloon-like pouches protruding from the groin region. These form at a natural point of weakness at the intersection of abdominal muscles.

Inguinal Hernias travel with the spermatic cord

Spermatic cord with testicular arteries and veins along with the vas deferens.
There is a natural opening in the abdominal wall which allows the spermatic cord to travel into the groin. When this opening enlarges, portions of the abdominal wall and its contents may pass through the same opening. Inguinal hernias typically follow the path of the spermatic cord.

The protrusions occurs when a loop of intestine or fat passes through this weak point and either enters the inguinal canal or pushes out just medial (more in the middle) to the inguinal canal. Men usually suffer from inguinal hernias developing in the groin, and may notice an ambiguous discomfort or even a bulge in the scrotum. Infants and children also suffer from inguinal hernias when a part of the lining of the abdominal cavity called the peritoneum does not close properly. This leads to a bulge in the groin because the intestine or other abdominal contents may push into the opening when the pressures inside the abdomen rise.

Direct Hernia

Direct hernia demonstrated medial to epigastric vessels
A direct hernia is the herniation of intestinal contents into a defect in the abdominal wall. This can include intestines as well as the bladder and other structures.

An example of this is when a patient coughs or has to strain while going to the bathroom. The squeezing that occurs in the abdomen can cause a hernia to protrude. Inguinal hernias can restrict blood supply to the bowel and may cause groin discomfort where there is pain when bending or lifting. Laparoscopic inguinal hernia repair is a surgical repair recommended for inguinal hernias that cause discomfort or for other groin hernias that are enlarging or bothersome. It is the preferred approach for bilateral inguinal hernia repair compared to open repair. The operation and technique is somewhat similar to other laparoscopic procedures. Laparoscopic inguinal hernia repair must be performed with the patient under general anesthesia. A small incision is made in or below the navel and then two additional small incisions are made. A portion of the abdomen is inflated with air so that the surgeon can see an operating space.

The preferred approach is a TEPP repair which stands for totally extraperitoneal pre-peritoneal repair. The imporant distinction here is the distinction ‘totally extraperitoneal’. This means that inside of the abdominal cavity is not filled with air but rather that the air goes between the inside muscle layer and where the hernia is located. It is performed in hospitals and is preferred by those who need to return home or to work quickly or for those having hernias on both sides. This surgery may not be recommended for those having incarcerated hernias, or having no tolerance to general anesthesia, and having bleeding disorders. People taking medicines for preventing blood clots, extremely obese persons and pregnant women are more difficult candidates for this surgery. If a patient has had many abdominal surgeries, it can sometimes complicate the laparoscopic hernia approach depending on the location of previous incisions. Scar tissue makes laparoscopic surgery more difficult to perform and optimally a surgeon can select a laparoscopic approach that goes around the scar tissue.

Rolling up and inguinal hernia mesh

Mesh being rolled up and inserted for laparoscopic inguinal hernia repair.
The mesh used for the surgery comes in a variety of different shapes and sizes. It is rolled up for insertion and then opened and placed into position under direct visualization.

The procedure

The surgeon makes small incisions on the abdominal wall to start the surgery. The layer of the abdomen just below the muscles is inflated with carbon dioxide and the laparoscope and surgical instruments are inserted through the incisions. With the help of a monitor, the surgeon pushes the hernited instestine into place and then uses a surgical mesh to repair the hernia opening.

Smaller Incisions used for Laparoscopic Repair

Laparoscopic groin hernia surgery uses smaller incisions then traditional open repair. The difference is most evident when performing bilateral repair.
Laparoscopic groin hernia surgery uses smaller incisions then traditional open repair. The difference is most evident when performing bilateral repair.

Advantages of laparoscopic inguinal hernia repair

The greatest advantage of laparoscopic inguinal hernia repair is that it offers a quicker recovery and thus shorter time off of work than the open repair. You can return home within 24 hours of the surgery and recover within 1 to 2 weeks. There is also a reduced risk of infection and the recurrence of hernias with this surgery, leading to less pain than open hernia surgery. The added advantages of laparoscopic inguinal hernia repair over open surgery is that the repair of the hernia may be easier with laparoscopic techniques. The surgeon can also check and repair a second hernia found at the opposite side during the operation. With the small incisions involved in this surgery, people prefer this surgery for cosmetic reasons.

Risks of laparoscopic inguinal hernia repair

Like all surgeries, there are some risks associated with laparoscopic inguinal hernia repair, where some people may need special preparation before the surgery. Those having a history of blood clots in large blood vessels, who smoke and those taking large doses of aspirin (as aspirin slows blood clotting and increases the chances of bleeding with surgery) are most vulnerable. Those on blood thinners and having urinary problems are also not advised the surgery. Some adverse outcomes associated with the surgery include pain in the spermatic cord, presence of fluid or blood in the scrotum and an inabiltiy to urinate. Other complications include from infections from the mesh or stitches, scar tissue formations called adhesions, and an injury to the abdominal organs, nerves and blood vessels. In very few patients, chronic complications include pain in the thigh, an injury to the testicle that leads to testicular atrophy, and a recurrence of the hernia.

Comparing laparoscopic inguinal hernia repair

When compared with open surgery, laparoscopic inguinal hernia repair uses several small incisions instead of a large, single cut. As the surgeon can examine both groin areas, both hernias can be repaired together without any second large incision. With the patch or mesh placed over weak areas of the groin, hernias can be prevented from recurring at the same spot. Theoretically it makes more sense than the open operation because the laparoscopic surgeon does not need to cut through the surrounding muscle layers in order to fix a problem in the same muscle layer. However, laparoscopic inguinal hernia repair is a technically difficult operation. Most doctors would agree that for a one-sided hernia repair- the differences between the open and laparoscopic approach is minimal and depends on your surgeon preference and experience. For operations however that require a bilateral repair (both sides) or if you have previously had a hernia repair and it has come back, then laparoscopic repair is typically preferred.

Bilateral Mesh inside muscle cavity

Bilateral inguinal hernia repair with TEPP mesh placement.
Another advantage of the laparoscopic approach is that the mesh fits into a natural space between the abdominal contents and the muscular wall. This means that coughing and straining does not affect the repair in the same way as it does with an open hernia repair.