Laparoscopic Inguinal Hernia Repair

Background

Laparoscopic inguinal hernia repair originated in the early 1990s as laparoscopy gained a foothold in general surgery. [12345Inguinal hernias account for 75% of all abdominal wall hernias, and with a lifetime risk of 27% in men and 3% in women. Repair of these hernias is one of the most commonly performed surgical procedures in the world. [6In the United States, approximately 800,000 inguinal herniorrhaphies are performed annually. [7]

Although open, mesh-based, tension-free repair remains the criterion standard, laparoscopic herniorrhaphy, in the hands of adequately trained surgeons, produces excellent results comparable to those of open repair. [89In a comparison between open repair and laparoscopic repair, Eklund et al found that 5 years after operation, 1.9% of patients who had undergone laparoscopic repair continued to report moderate or severe pain, compared with 3.5% of those who had undergone open repair. [10]

A number of studies have shown laparoscopic repair of inguinal hernias to have advantages over conventional repair, including the following [1112131415:

  • Reduced postoperative pain
  • Diminished requirement for narcotics
  • Earlier return to work

Laparoscopic repair has some disadvantages as well, including the following:

  • Increased cost
  • Lengthier operation
  • Steeper learning curve
  • Higher recurrence and complication rates early in a surgeon’s experience

The term laparoscopic inguinal herniorrhaphy can refer to any of the following three techniques:

  • Totally extraperitoneal (TEP) repair
  • Transabdominal preperitoneal (TAPP) repair
  • Intraperitoneal onlay mesh (IPOM) repair [16171819]

The IPOM repair has largely fallen from favor, and currently, the most commonly performed laparoscopic techniques are the TEP and TAPP repairs. [14158Although many facets of laparoscopic inguinal hernia repair continue to be debated—such as the possible superiority of one laparoscopic approach to another, comparisons between laparoscopic and open surgery, the learning curve and training issues, and the socioeconomic implications—both TAPP and TEP have been shown to be acceptable and safe for repair of inguinal hernias.

For information on manual reduction of hernias, see Hernia Reduction. For a discussion of open repair, see Open Inguinal Hernia Repair.

Indications

The general indications for laparoscopic inguinal hernia repair as opposed to watchful waiting are the same as those for open inguinal hernia repair.

Classically, the existence of an inguinal hernia has been considered sufficient reason for operative intervention. However, studies have shown that the presence of a reducible hernia is not, in itself, an indication for surgery and that the risk of incarceration is less than 1%. [20]

Symptomatic patients (with pain or discomfort) should undergo repair; however, as many as one third of patients with inguinal hernias are asymptomatic. [20The issue of observation versus surgical intervention in this asymptomatic or minimally symptomatic population was addressed in two randomized clinical trials, both of which found that there were no significant differences in hernia-related symptoms after long-term follow-up and that watchful waiting did not increase the complication rate. [2122]

In one study, the substantial patient crossover from the observation group to the surgery arm led the authors to conclude that observation may delay but not prevent surgery. [20This reasoning holds particularly true for younger patients. Thus, even an asymptomatic patient, if medically fit, should be offered surgical repair. In another study, the authors determined that most patients with a painless inguinal hernia will develop symptoms over time and that surgery is therefore recommended for medically fit patients. [23]

Some reports have listed specific indications for laparoscopy over open repair, including recurrent hernias, bilateral hernias, and the need for earlier return to full activities. [24252613272829]

Several studies have demonstrated salutary outcomes for laparoscopic repair of recurrent hernias. [25303124Re-recurrence rates may decline to 5% or lower with laparoscopic repair, [253233compared with rates as high as 20% for anterior repair. [34]

The reduced pain after laparoscopic inguinal hernia repair as compared with conventional anterior repair makes laparoscopy the approach of choice for bilateral hernias. [353637A particular advantage of TAPP repair in a patient with bilateral inguinal hernias is that both sides can be repaired via the same laparoscopic port sites.

The choice of repair for primary unilateral inguinal hernias is controversial. A large Veterans Affairs cooperative study reported a 10% recurrence rate for laparoscopic inguinal hernia repair, compared with a 5% rate for anterior repair [9; however, multiple authors identified flaws with this study. [3839Other studies from experienced hernia surgeons have reported recurrence rates for laparoscopic repair that range from 1% to 3%. [404142]

Although the actual hospital costs of laparoscopic repairs are higher than those of open repairs, the increased cost may be offset by the societal benefits of earlier return to full activities. [843]

Patient preference plays perhaps the greatest role in the choice of one type of repair over another; however, surgical expertise plays a key part as well. Data show that the recurrence rate drops significantly as surgeons gain experience with the laparoscopic technique. Some studies suggest that the learning curve for TEP laparoscopic herniorrhaphy may be as high as 250 cases (as opposed to 25 for open repair). [9TAPP repair has a learning curve closer to that of the open technique. [44]

A Cochrane database meta-analysis comparing TEP with TAPP found no significant difference in recurrence rates but did find that TAPP was associated with a higher risk of intra-abdominal injury. The authors concluded that further randomized controlled trials are needed for definitive comparison of these two techniques. [45]

Conclusions about inguinal hernias in female patients are difficult to draw because most of the literature involves male patients. Koch et al found that recurrence rates were higher in women and that recurrence was 10 times more likely to be femoral in women than in men. [46This has led some to conclude that approaches that cover the femoral space (eg, laparoscopic repair) at the time of initial operation are better suited for primary repair in women. [47Further studies will be needed to resolve this question.

The IPOM technique has fallen out of favor because of reports of unacceptably high rates of organ injury, nerve injury, and hernia recurrence. [26]

Contraindications

General contraindications for laparoscopic herniorrhaphy parallel those of open repair.

Inguinal hernia repair itself has no absolute contraindications. Just as in any other elective surgical procedure, the patient must be medically optimized. Any medical issues, whether acute (eg, upper respiratory tract or skin infection) or exacerbations of underlying medical conditions (eg, poorly controlled diabetes mellitus), should be fully addressed and the surgery delayed accordingly.

Patients with elevated American Society of Anesthesiologists (ASA) scores and high operative risk should undergo a full preoperative workup and determination of the risk-to-benefit ratio.

Relative contraindications specific to the laparoscopic approach include a lower midline incision, previous preperitoneal surgery (eg, prostatectomy), irreducible hernia, and inability to tolerate general anesthesia.

TEP repair

To undergo TEP repair, patients must be able to tolerate general anesthesia. Although TEP repair has been performed with regional anesthesia, [4849it is most commonly performed with general anesthesia, and transition from regional to general anesthesia might be required. Patients whose comorbidities preclude general anesthesia should undergo anterior repair under a local or regional anesthetic.

Previous operations in the preperitoneal space (eg, retropubic prostatectomy and TEP) can make TEP repair difficult. TEP is usually facilitated by using space-creating balloons, which generally function poorly when dense adhesions are present in the space of Retzius. Holes in the peritoneum are common in reoperative preperitoneal surgery. A better choice for laparoscopic repair in patients who have previously undergone a preperitoneal operation is TAPP; an anterior repair through an unadulterated plane may be an even better option.

Some surgeons consider previous open appendectomy a relative contraindication for TEP repair in patients with right inguinal hernias. [28On occasion, the appendectomy scar complicates the lateral dissection, but this does not preclude a safe and effective TEP repair.

Previous low midline incisions can also make TEP repair more difficult, though not impossible. Access to the preperitoneal space might have to be moved to a more lateral location rather than the standard location in the midline. Once access is achieved, TEP repair usually proceeds as normal in patients with previous low laparotomies, though some studies report a higher rate of visceral injury in these cases.

TAPP repair

Absolute contraindications for TAPP repair are few. In general, the inability to tolerate general anesthesia is considered an absolute contraindication, though there are reports of spinal anesthesia being used for this procedure. [5051Other absolute contraindications are coagulopathy (because bleeding in the preperitoneal space can be difficult to assess and control postoperatively) and intra-abdominal infections that limit the use of prosthetic meshes.

Relative contraindications include previous abdominal surgery, especially pelvic surgery, and depend on the type and degree of expected adhesions, the surgeon’s level of comfort with adhesiolysis, and the nature of the hernia.

Previous prostate surgery was once thought to be an absolute contraindication, in that it would necessarily have disrupted the preperitoneal space. With improvement in techniques and familiarity with the TAPP procedure, previous prostate surgery is now considered a relative contraindication, and TAPP has been shown to be safe in this setting. [52However, surgeons should be aware that TAPP repairs in patients who have undergone prostatectomy are more difficult and carry a higher morbidity.

Large inguinoscrotal hernias, though not a contraindication, can be challenging to manage because reducing these indirect sacs laparoscopically can be difficult. Patients with such hernias, especially when being operated on by an inexperienced surgeon, may be better served by an open approach.

It is important for surgeons to weigh the risks and benefits of TAPP repair against those of open repair. Thorough knowledge of the proposed benefits, indications, and contraindications of TAPP repair as compared with TEP and open repairs is essential and will help the surgeon tailor the surgical approach to the individual patient and the particular clinical scenario.

Technical Considerations

Anatomic considerations

Poor familiarity with the complex anatomy of the posterior inguinal view is an important contributor to the steepness of the learning curve for laparoscopic inguinal herniorrhaphy. [535455Although the following discussion describes the anatomy from a laparoscopic point of view, a working knowledge of the inguinal region and the anterior abdominal wall remains paramount. For a detailed description of the region, see Open Hernia Inguinal Repair.

The preperitoneal space is contained between the transversalis fascia and the parietal peritoneum. It contains areolar and adipose tissue and the inferior epigastric artery and vein.

Transabdominal laparoscopic landmarks useful when performing the TAPP repair are the obliterated fetal remnants, which divide the posterior surface of the anterior abdominal wall into three fossae as follows [56:

  • The median umbilical ligament is a remnant of the embryonic urachus; it forms the center divide by arising in the midline from the apex of the bladder toward the umbilicus
  • Laterally, the paired medial umbilical ligaments, vestiges of the fetal umbilical arteries, arise from the superior vesicle arteries toward the umbilicus
  • Between the median and medial ligaments lie the supravesical fossae, where external supravesical hernias occur
  • Most lateral are the paired lateral umbilical ligaments, which contain the inferior epigastric arteries; between them and the medial ligaments lies the medial fossa, which contains the Hesselbach triangle (the zone of direct hernias), and lateral to the inferior epigastric arteries is the lateral fossa (the site of indirect hernias); thus, the lateral umbilical ligaments separate the lateral and medial fossae and differentiate indirect from direct hernias

There are three key anatomic landmarks in the preperitoneal space that are constant in their presence and location (see the image below). They are a good starting point for getting one’s bearings in this difficult region and may also be helpful in cases of large hernias or recurrences. These landmarks are as follows:

  • Inferior epigastric vessels
  • Cooper ligament
  • Iliopubic tract
Inguinal anatomy from laparoscopic viewpoint. Inguinal anatomy from laparoscopic viewpoint.

The inferior epigastric artery-vein complex lies on the rectus muscles bilaterally. Medial to these vessels but above the iliopubic tract is the external ring, which is not visible in patients without a direct hernia. The internal ring is lateral to the inferior epigastric vessels but is often obscured by them, even when a hernia is present. Its location can be approximated by locating the junction of these vessels and the cord structures. The femoral ring is inferior and lateral to the external ring and lies below the iliopubic tract just medial to the external iliac vessels.

The Cooper ligament is the name given to the periosteum of the superior pubic ramus. The pubic ramus can be easily palpated with a blunt grasper and is an excellent starting point for dissection.

Also deserving of careful recognition is the iliopubic tract (commonly referred to as the shelving edge of the inguinal ligament in open surgery). This aponeurotic stretch of tissue is located posterior to the inguinal ligament and extends from the anterior superior iliac spine to the superior pubic ramus. As a continuation of the transversus abdominis aponeurosis and fascia at the upper border of the femoral sheath, it passes medially to form the inferior border of the internal inguinal ring, crossing over the femoral vessels. [565758]

The surgeon must be aware that the iliopubic tract forms the superolateral border of the so-called triangle of pain, an area bounded medially by the spermatic vessels (see the image below). In this area, tacking of the mesh is to be avoided because of the risk of injury to the femoral branch of the genitofemoral nerve or the lateral femoral cutaneous nerve. [53565745]

Inguinal anatomy: triangle of pain. Inguinal anatomy: triangle of pain.

Another anatomic zone of which the surgeon must be aware is the so-called triangle of doom, which is bordered medially by the ductus deferens and laterally by the spermatic vessels, with its apex at the deep inguinal ring (see the image below). This area contains the external iliac artery and vein; thus, tacking of the mesh must be avoided within its boundaries, and dissection should be limited. [5658]

Inguinal anatomy: triangle of doom. Inguinal anatomy: triangle of doom.

Other vascular structures should be considered during TEP. There may be a vascular connection between the obturator and external iliac systems, producing a so-called corona mortis. This abnormality is commonly encountered as dissection of the Cooper ligament is taken toward the external iliac vein. Gentle and judicious dissection will limit injury to this structure. Other small veins surround the Cooper ligament and can lead to meddlesome bleeding during TEP.

The surgeon should be mindful of the important nerves in the area as well. The lateral femoral cutaneous nerve travels along the iliopsoas muscle as the nerve courses toward the lateral thigh. The genitofemoral nerve emerges from the psoas muscle medial to the lateral femoral cutaneous nerve. The genital branch of this nerve courses lateral to the spermatic cord and travels through the deep inguinal ring. Both the femoral branch of the genitofemoral nerve and the femoral nerve lie in close proximity to the femoral artery.

Complication prevention

Accurate identification of the laparoscopic anatomy of the groin during laparoscopic inguinal hernia repair helps prevent complications. Careful attention to detail at several points during the surgical procedure can also be helpful. Appropriate positioning and padding can help prevent nerve palsy.

The inferior epigastric vessels may be dislodged by the dissecting balloon used in TEP repair, and this can either cause significant bleeding or impede the dissection. The inferior epigastric vessels can be clipped and divided without consequence. If the bleeding occurs with the vessels in situ, a transabdominal wall suture ligature may be used to control the bleeding. In TAPP repair, starting the peritoneal dissection in the right plane helps prevent injuries to the inferior epigastric vessels during the creation of the peritoneal flap.

Hematoma or seroma formation may occur but is usually self-limited because of the tamponade effect of the peritoneum. On rare occasions, surgical intervention may be necessary.

Small holes in the peritoneum can lead to encroachment of the peritoneum into the working space. This can be remedied in multiple ways, such as by enlarging the hole to equilibrate the intra-abdominal pressure with the preperitoneal pressure, by placing a Veress needle into the abdomen to evacuate the intra-abdominal gas, or by closing the hole securely to prevent passage of carbon dioxide into the peritoneal cavity.

All holes in the peritoneum should be repaired. Large holes do not lead to diminished working space but can lead to postoperative complications. Exposed mesh can lead to adhesions to the small bowel and, in rare cases, bowel injury and fistulization. [596061A peritoneal rent can also serve as a site for bowel to become incarcerated. [62Peritoneal rents may be closed with sutures, clips, or preformed suture ligatures.

It is particularly important to try to avoid tearing of the peritoneal flap during TAPP; this can be difficult, because the peritoneum can be very flimsy. Tearing the peritoneum may not be a significant complication for this repair, but it will add extra time to the procedure and can complicate peritoneal closure and coverage of the mesh. When the peritoneum is torn and cannot be repaired, a barrier-type mesh or one suitable for intra-abdominal placement can be used. However, this is not ideal, because the peritoneum helps hold the mesh in place.

Intra-abdominal injury is uncommon with TEP repair but may occur if the peritoneum is torn and the abdominal cavity entered. Extra care should be taken with wide-neck hernia sacs that contain abdominal organs. A final intraperitoneal evaluation may be helpful at the completion of the case if an injury is suspected. The potential for intra-abdominal injury is one of the drawbacks of TAPP repair; thus, safe laparoscopic access is essential. Surgeons should employ the laparoscopic access techniques with which they feel most comfortable. [6364]

Obviously, cautious hernia reduction and careful identification of the vas deferens and cord structures are crucial for avoiding complications. Large indirect hernia sacs may be difficult to reduce; their chronicity often results in adherence of the sac to the cord. If, after a diligent effort, the sac cannot be reduced, it can be divided. The sac and cord structures should be clearly separated, and the sac should be free of contents. A cold scissors can be used to divide the sac. The proximal sac should be closed with a suture ligature and the distal sac left open.

Adhesion formation is very uncommon with TEP repair but has been reported with large peritoneal rents. Closure of the defect may be warranted and can be performed laparoscopically with endoscopic clips or an endoscopic loop ligature.

Pain (acute postoperative or chronic) is another potential complication. Injury to the nerves during dissection is a common cause of chronic pain. Such injury can be avoided by gentle dissection in the lateral space inferior to the iliopubic tract and lateral to the spermatic vessels. Great care must be exercised in securing the mesh with tacks. Awareness of the groin anatomy will help surgeons fix the mesh without injuring critical nerves. Nerve injury is usually self-limited but may have to be treated with steroid injections or, if persistent, neurectomy.

Ischemic orchitis leading to atrophic testicle or even necrosis is a catastrophic but known complication of inguinal herniorrhaphy. The exact cause of this vascular injury is unclear, but it is thought to be secondary to venous thrombosis rather than arterial injury. Although this complication is rare, a high index of suspicion should be maintained; this, in conjunction with emergency testicular ultrasonography, may help avoid orchiectomy. Symptoms of ischemic orchitis include painful testicular swelling and fever commencing 2-3 days after surgery. [65]

A study comparing heavyweight and lightweight meshes for laparoscopic inguinal hernia repair in men found that the use of lightweight mesh for bilateral repair negatively influenced sperm motility. [66A prospective randomized study involving 59 male patients found that at 1-year follow-up, sperm motility had declined from preoperative levels in patients receiving lightweight mesh but had increased slightly in those receiving heavyweight mesh. No differences in quality of life were noted between recipients of different types of mesh. [67]

Outcomes

As with any hernia repair, postoperative complications are possible. Morbidity is usually low after a TAPP procedure, with one large series reporting a rate of 2.9%. [68Seromas represent the most common postoperative complication. These usually resolve spontaneously and rarely warrant further intervention (eg, aspiration).

Recurrence is a concern. A large randomized, controlled trial comparing laparoscopic with open repair found that with adequate training, laparoscopic repair yielded equivalent recurrence rates, reduced postoperative pain, and earlier return to work. [24Recurrence rates after TAPP repair usually range from 1% to 6%; specialized centers performing large numbers of repairs cite rates of less than 1%. [27686970]

Small-bowel obstruction is a rare complication after a TAPP hernia repair and most commonly results from holes created in the peritoneal flap during dissection. As a rule, it is easily prevented by repairing these tears or holes and ensuring proper tacking of the peritoneum to the abdominal wall over the mesh, so that there are no potential holes or gaps through which bowel can herniate.

With respect to outcome, TEP appears to have several advantages over TAPP, including the following [3717273:

  • Less risk of intraperitoneal injury
  • Fewer intra-abdominal adhesions
  • No need to close a large peritoneal envelope

Many surgeons find the working space confining when they first perform TEP repairs, but this challenge can be overcome with experience. Mastery of the anatomy of the preperitoneal space and meticulous surgical technique conduce to favorable outcomes after TEP.


Patient Education and Consent

Special patient preparations are minimal for totally extraperitoneal (TEP) repair. Patients should not eat after midnight before the operation. Shaving the operative site before arrival at the hospital should be discouraged.

Informed consent should center on the alternatives to TEP and on potential complications, including recurrence. Patients should be aware that TEP requires general anesthesia, which carries its own attendant risks. An alternative is an anterior repair with local anesthesia.

There are several complications that are potentially severe in TEP but typically negligible in anterior repairs. Life-threatening hemorrhage due to major vascular injuries is possible. Entry into the peritoneum may occur during the procedure potentially resulting in visceral injury and adhesions.

Patients who are undergoing laparoscopic repairs should be educated regarding expected postoperative pain, possible temporary discoloration of the groin and scrotum, and seroma formation within the first few postoperative days. It is also important to discuss the possibility of nerve injury and chronic postoperative pain (defined as pain lasting longer than 6 months). Although this is an uncommon result, it can be highly frustrating to the patient and should therefore be addressed beforehand.

Patients undergoing a unilateral laparoscopic repair should be counseled on the possibility that bilateral hernia repair may be necessary if a contralateral hernia is encountered during surgery. Consent for this procedure should be obtained.

Equipment

Instruments

All methods of laparoscopic hernia repair require the following standard laparoscopic equipment:

  • Blunt graspers
  • A 30° laparoscope
  • A tacking device or fibrin glue applicator system

A laparoscopic clip applier and suction irrigator should be available on standby.

It is common to place a Foley catheter so as to decompress the bladder and maximize the preperitoneal space. Patients who are undergoing unilateral hernia repair (a short procedure) and have no history of urinary retention can probably avoid placement of a Foley catheter if they void immediately prior to the operation.

In a TEP repair, most surgeons use specialized dissecting balloons for the initial dissection of the preperitoneal space. This saves time but does add some cost. Alternatively, the preperitoneal space can be created by means of simple blunt dissection with the laparoscope. Some surgeons prefer to use an integrated trocar−dissector balloon system to prevent evacuation of the carbon dioxide from the preperitoneal space. In addition, a 5-mm trocar and an 11-mm trocar are typically placed.

Standard laparoscopic trays usually have all the instruments needed for a transabdominal preperitoneal (TAPP) repair. The authors commonly place a pair of 5-mm trocars and one 11-mm trocar. A reusable suture passer may also be useful for closing the 11-mm fascial incision at the umbilicus.

Mesh

Choice of mesh

The mesh used for the repair must be a permanent material cut to a size large enough to produce a wide overlap beyond the defect’s edges. The choice of material depends on surgeon preference; both lightweight polypropylene and polyester are good choices. The size may range from 5 × 10 cm to 10 × 15 cm. The mesh can either be flat and rectangular or preformed to fit the myopectineal orifice. Although some surgeons prefer anatomic mesh configurations, a flat sheet works just as well and is more cost-effective.

In general, a standard uncoated mesh is used for laparoscopic repairs, because the mesh will be shielded from the intra-abdominal organs by the peritoneum. When the peritoneum is torn and cannot be repaired, coated polypropylene or polyester-based meshes or other meshes approved for intra-abdominal applications (eg, expanded polytetrafluoroethylene [ePTFE]) can be used.

Although further study remains necessary, it appears that lightweight meshes may have some advantages over standard heavyweight polypropylene meshes with regard to the development of postoperative pain and discomfort after inguinal hernia repair. [7475767778]

Approach to mesh fixation

Whether to fix the mesh in place and which type of fixation device to use are matters of individual surgeon preference. The many options for mesh fixation currently available give the surgeon a range of choices.

In TEP repair, titanium spiral tacks are commonly used to affix the mesh to the Cooper ligament superomedially and superolaterally. Use of more than five tacks has been shown to correlate with higher rates of chronic postoperative pain. [79Absorbable tacks may be a useful alternative; they are made of a specialized polymer that disintegrates after 4-10 weeks, allowing ample time for the collagen to grow into the interstices of the mesh to anchor it in place.

In TAPP repair, titanium tacks also have traditionally been used to fix the mesh and can also be used to close the peritoneal flap. However, a 2011 report showed that acute pain was increased when more than 10 tacks were placed. [80A number of surgeons have now switched to using absorbable tacks to fix the mesh and close the peritoneum. Sutures or hernia stapling devices can also be employed.

Some authors have advocated the use of fibrin glue to fixate the mesh. [818265A specialized laparoscopic device can be deployed to direct the application of the fibrin glue. More widely used in Europe, glue fixation appears to be a promising means of decreasing chronic pain. [83]

Still other authors use no fixation at all but instead rely on peritoneal pressure to maintain the mesh in proper position. [848562Short-term study results have been generally favorable, though most surgeons still prefer to employ some method of fixation. An alternative to no fixation might be the use of self-fixating mesh. This product is new to the market, and its efficacy remains to be determined.

Patient Preparation

Anesthesia

Although a TEP repair can be performed with epidural anesthesia, general anesthesia is preferred as a rule.

Elective inguinal hernia repair is considered a clean procedure (< 2% rate of surgical site infection). Although the data currently available are not conclusive, one meta-analysis supports the use of antibiotic prophylaxis when performing a mesh-based repair. [86Typically, a single dose of a cephalosporin (eg, cefazolin) is administered by the anesthesiologist before the skin incision. [87A definitive answer to the antibiotic question awaits the performance of a properly powered, well-constructed, prospective, randomized study.

General anesthesia is usually required for a TAPP repair, though there are reports of spinal anesthesia being used. [5051If a patient cannot tolerate or prefers not to undergo general anesthesia, open repair should be considered.

Positioning

The correct surgical site is confirmed and marked preoperatively in the holding area. The patient is placed in the supine position on the operating table. For large defects, slight Trendelenburg positioning may facilitate exposure by reducing the visceral contents into the abdomen.

The upper extremities are comfortably padded and tucked at the sides. (Some surgeons leave the arms out on armboards.) Even when a unilateral repair is scheduled, it is important to secure both arms, so that if an occult hernia is found on the contralateral side, it can be fixed during the same procedure.

The surgical site is shaved with electric clippers, then prepared and draped in standard surgical fashion so as to expose an extending area from above the umbilicus to below the pubis. The prepared area should be wide enough to permit conversion to an open technique if this should become necessary.

The operating surgeon stands on the side opposite the hernia, and the assistant stands on the side of the hernia. A single monitor or a pair of monitors may be placed at the foot of the bed. It is most convenient to have the light source, the carbon dioxide insufflator, and the video processor situated at the foot of the bed, though alternative locations will also work.

Monitoring and Follow-up

Most patients who have undergone a TEP procedure can be discharged on the day of the operation. Because urinary retention occasionally develops, all patients should be able to void before discharge. Patients should also be told to expect some ecchymosis at the base of the penis and some temporary edema of the testes. Narcotic pain medicine is usually required for 2-3 days after the operation.

While the postoperative course is generally uncomplicated, patients must be routinely instructed to recognize certain signs and symptoms that can alert them to the potential complications as discussed above. [8889]

Large-scale studies examining the convalescence period after elective inguinal herniorrhaphy determined that the median length of absence from work was 7 days when patients were advised by their surgeons to limit the recuperation period and to resume normal activities within 1 day after the procedure. Moreover, these studies confirmed that early resumption of activities (including exercise) did not increase the risk of recurrence. Thus, with adequate analgesia, patients can safely return to their daily duties. [8889]

After a TEP repair, patients should be seen in the office for a follow-up visit within 1 month (ideally, within 1 week). Patients who had large hernias often have seromas, which can be easily differentiated from recurrent hernias on examination, in that a seroma is a distinct fluid collection that is not reducible. If the diagnosis is in doubt, ultrasonography may be useful. Most seromas resolve within 6 weeks of the operation. After the initial visit, follow-up may be scheduled on an as-needed basis.

Long-term monitoring for a TAPP repair is much the same as that for other hernia repair techniques. Routine follow-up in 1-2 weeks is warranted for checking the wound and assessing the patient’s overall condition. Longer-term follow-up is scheduled on an as-needed basis. Because hernia recurrences typically do not manifest until 6-12 months after the repair, long-term follow-up will be necessary in some cases. Patients should be counseled about the signs and symptoms of hernia recurrences and followed as needed.

Typically, postoperative pain resolves or greatly decreases by the first postoperative visit. Patients with ongoing pain issues after surgery require frequent office visits and complex multidisciplinary treatment that includes pain specialists and physical therapists; in some instances, surgical treatment will subsequently be required.

Because patients often do not return to their primary surgeon for long-term follow-up, surgeons who perform TAPP procedures should consider keeping a database of their patients or becoming involved in national registries to assess long-term outcomes.

Approach Considerations

A number of considerations should be kept in mind in the performance of laparoscopic inguinal repair, whether via the totally extraperitoneal (TEP) approach or via the transabdominal preperitoneal (TAPP) approach.

Extreme care must be exercised in placing the mesh fixation tacks. This point cannot be overstated. A nerve injury caused by an errant tack can be truly debilitating to the patient and very challenging to treat. Tacks should be placed only above the iliopubic tract. [90Proper placement may be ensured by drawing a line from the pubic tubercle to the anterior superior iliac spine (ASIS) at the start of the procedure. Before firing each tack, carefully palpate the tacker head through the abdominal wall to ensure that it is above this line.

Violation of the peritoneum during TEP repair causes loss of insufflation from the preperitoneal space into the peritoneal cavity, which, in turn, causes the preperitoneal space to collapse to some degree. This collapse can make the procedure more difficult to complete; in addition, it places intra-abdominal organs at risk for injury and may lead to adhesion formation.

Accordingly, efforts should always be made to avoid tearing the peritoneum if at all possible. If the rent is small, endoscopic clips can be placed to close the defect and minimize the leak. Otherwise, conversion to a TAPP repair or an open repair may be necessary. Another option is to place a Veress needle through a stab incision into the abdominal cavity to drain the carbon dioxide.

Trocar placement should always be done under direct vision. To prevent bleeding and hematoma formation, the trocars should be placed exactly in the midline so as to avoid tearing the fibers of the rectus abdominis.

During preperitoneal dissection, the inferior epigastric artery and vein sometimes become separated from the abdominal wall and then hang down into the operative field. Clipping and dividing these vessels may be required in order to complete the procedure.

It is very helpful to place the mesh in such a way as to facilitate its subsequent flush deployment. This may be accomplished by folding the mesh in half lengthwise, grasping it by the fold, and advancing it through the trocar toward the ASIS. When the grasper is released, the natural memory of the mesh causes it to spring open in a properly oriented position, without any need for time-consuming manipulation.

Vascular injury is a relatively uncommon but nonetheless potentially disastrous adverse event. It can be avoided by respecting the proximity of the femoral vessels, particularly when the mesh is being tacked to the Cooper ligament. [91]

Recurrence of the hernia is a significant concern. The key to minimizing the recurrence rate is to use an ample-sized piece of mesh. The mesh must be large enough to extend 2 cm medial to the pubic tubercle, 3-4 cm above the Hesselbach triangle, and 5-6 cm lateral to the internal ring.

If the patient is male, the surgeon should always remember to pull the testes gently back down to their normal scrotal position at the end of the procedure.

Totally Extraperitoneal Repair

Before independently performing a TEP repair, surgeons should receive specific training in the technique. [92Sound laparoscopic skills provide a solid foundation, but mentoring in the technique leads to improved outcomes. Mentoring is most valuable with regard to gaining familiarity with the preperitoneal anatomy and its variations. A complete TEP procedure is shown in the video below.Laparoscopic inguinal hernia repair: TEP. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Variations of TEP repair that use only one port have been described; some promising results have been obtained, but further study is required. [9394]

Laparoscopic access and port placement

A 10-mm longitudinal or a curvilinear infraumbilical skin incision is made, and then deepened to separate the subcutaneous fat and expose the anterior rectus sheath. [56]

Next, a longitudinal incision is made in the anterior rectus sheath slightly off the midline over the body of the rectus abdominis (thus avoiding entering the peritoneal space in the midline, where the anterior and posterior rectus sheaths merge). [565713The midline raphe is grasped with a Kelly clamp, and the underlying rectus muscle fibers are retracted laterally, revealing the glistening white surface of the posterior rectus sheath.

With the posterior rectus sheath as a guide, a dissecting balloon is introduced and slipped along the rectus sheath (see the video below). The balloon is advanced past the arcuate line and into the preperitoneal space, down to the pubic symphysis. The dissecting balloon is then inflated under direct laparoscopic vision (ie, with the scope in the lumen of the balloon) to dissect the preperitoneal space. [56571395]Laparoscopic inguinal hernia repair: TEP. Balloon dissection.

Instead of pumping the dissecting balloon to a preset number of pumps (30-40, according to manufacturer recommendations), it may be preferable to pump under direct vision until no further movement of the tissues is visible, indicating no benefit from further dissection.

Once adequate dissection is attained, the dissecting balloon is deflated and removed. The patient is then placed in the reverse Trendelenburg position, and the preperitoneal space is insufflated with carbon dioxide to a pressure of 12 mm Hg.

A 10-mm 30° laparoscope is introduced through the umbilical port, [565713and a visual inspection is performed. When the preperitoneal space is properly accessed, the undersurface of the rectus muscles should be visualized at the top of the operative field. Two additional ports are placed in the midline between the umbilicus and pubis: a 5-mm trocar, placed two fingerbreadths cephalad to the pubic symphysis, and a 5- or 11-mm trocar, placed at the midway point between the lower port and the camera port (see the image below).

Laparoscopic inguinal hernia repair: TEP. Trocar pLaparoscopic inguinal hernia repair: TEP. Trocar placement.

Dissection

The most consistent anatomic landmark in this area is the Cooper ligament. It is common to begin the dissection with exposure of the Cooper ligament and the pubic tubercle. This can be done with a two-handed technique, whereby two blunt graspers are placed against the bone at a single point, then gently spread apart (see the video below). Gentle dissection with meticulous hemostasis is continued to expose the direct space and the femoral space by clearing the Cooper ligament down to the iliac vessels.Laparoscopic inguinal hernia repair: TEP. Direct space dissection.

Direct and femoral hernias will be encountered during this initial dissection. A direct hernia often reduces spontaneously with pneumopreperitoneum, but careful, gentle traction and freeing of fibrous bands may be necessary to achieve complete reduction. Clearing the Cooper ligament in its entirety ensures that a direct hernia is fully reduced. On occasion, a large direct hernia may obscure the anatomy, in which case its reduction should be postponed until other anatomic structures are clarified.

Great care must be exercised as the dissection approaches the iliac vessels. In addition, obturator vessels often cross the dissection planes and may need to be clipped and divided.

The inferior epigastric vessels are identified, and dissection lateral to the vessels leads to the space of Bogros, the cord structures, and indirect hernias (see the video below). The proper plane of dissection is between the transversalis fascia and the peritoneum. This is identified by retracting the inferior epigastric vessels upward against the rectus muscle. A plane containing areolar tissue is identified, and this plane is dissected toward the pelvic sidewall. [56571395]Laparoscopic inguinal hernia repair: TEP. Lateral abdominal wall dissection.

Care must be exercised in separating the peritoneum from the muscle layers of the abdominal wall. The peritoneum is often very thin and may be tightly adherent. Attempting to disconnect these structures may result in a peritoneal rent; this is especially evident cephalad. Inferolaterally, the abdominal wall must be cleared to below the iliopubic tract.

Management of hernia sac

After the initial medial and lateral dissection, the surgeon should assess the anatomy and location of the hernia. The Cooper ligament should be clearly visualized. Small direct hernias may already have been reduced by the dissecting balloon, rendering the defect visible. The location of the cord structures should be clear. Cord lipomas and indirect hernias lie lateral to the cord structures. The location of the external iliac vein should be assessed; it may not yet be eminently clear, but the approximate location should be noted.

With the anatomy clarified, the hernias can now be safely reduced. Direct and femoral hernias are reduced by applying cephalad traction to the hernia sac with appropriate countertraction (see the video below). The trajectory of dissection should be away from the external iliac vessels.Laparoscopic inguinal hernia repair: TEP. Reduction of small direct hernia.

Next, attention is shifted to the internal ring to identify an indirect hernia sac, which may be more difficult to reduce than a direct hernia. The indirect hernia sac is located on the superolateral aspect of the spermatic cord as it enters the deep inguinal ring. It is carefully and gently separated from the cord structures by elevating the cord-sac bundle and then delicately stripping the areolar tissue downward until a window is found between the sac and the cord structures (see the video below). [56571395]Laparoscopic inguinal hernia repair: TEP. Indirect sac isolation.

Once the sac is separated cephalad, retraction of the sac from its apex typically allows it to be reduced. Cord lipomas may also be visualized during these maneuvers. They are situated lateral to the cord and course toward the deep ring. Cord lipomas should be reduced cephalad and laterally.

If the sac cannot be reduced back into the peritoneal cavity, it should be ligated proximally and left open to drain distally so as to prevent hydrocele formation. The simplest way of doing this in a wide-mouth sac is to fire a vascular 30-mm linear stapler across the sac and then divide the sac distal to the staple line. An alternative method is to use endoscopic clips or an endoscopic loop ligature. Care must be taken to avoid injury to any intra-abdominal sac contents or sliding component.

Placement and fixation of mesh

Wide preperitoneal dissection ensures that adequate space is available for placement of a large mesh prosthesis. The lateral dissection should take the peritoneum up to the umbilicus. The peritoneum should be taken off the spermatic vessels as far cephalad as possible (see the video below). The peritoneum should be dissected off the vas deferens to the point where the vas courses medially. The external iliac vein should be visualized by dissecting the overlying fatty tissue medially, toward the urinary bladder. Finally, the obturator space should be dissected.Laparoscopic inguinal hernia repair: TEP. Dissection of peritoneum off cord with small hole in peritoneum.

After this complete and meticulous dissection, the operative site is assessed. The deep ring should be visualized with only the cord structures traversing its opening into the inguinal canal. Any holes that were made in the peritoneum should be closed before placement of the mesh.

Once the requisite dissection is complete, the mesh is folded and introduced under direct vision, then dragged as far laterally as possible toward the ASIS (see the videos below). Next, the mesh is flattened out across the myopectineal orifice and draped over the cord structures. A single tack is placed at the pubic tubercle; this serves as a fixation point to facilitate arrangement of the mesh in the tight preperitoneal space.Laparoscopic inguinal hernia repair: TEP. Pearl mesh deployment.

The mesh is maneuvered so that its upper border lies above a line from the pubic symphysis to the ASIS. The remaining tacks are then placed down the Cooper ligament, up the midline, and along the upper border of the mesh.

It is essential that each firing of the tacker beyond the inferior epigastric artery-vein complex be above a line from the pubic symphysis to the ASIS. This ensures that no tacks are placed in proximity to nerve structures or iliac vessels (the triangle of pain and triangle of doom). Correct placement can be further verified by carefully palpating the tacker head through the abdominal wall and comparing its relation to this line before each firing. No more than one or two tacks are needed in this hazardous location.

If the patient has bilateral pathology, the surgical team’s attention is now turned to the contralateral side.

Port removal and closure

At the completion of the operation but before desufflation, an additional step that may be considered is to spray the preperitoneal space with 20 mL of 0.5% bupivacaine with epinephrine for long-acting local analgesia and improved hemostasis (see the video below). [96]

Laparoscopic inguinal hernia repair: TEP. Local anesthesia infiltration.

While the preperitoneal space is being desufflated under direct vision, a blunt grasper should be placed against the lower corner of the mesh just lateral to the cord structures (see the image below). This prevents the mesh from rolling upward and exposing the lateral aspect of the internal ring to recurrence.Laparoscopic inguinal hernia repair: TEP. Desufflation.

Finally, larger trocar site fascial defects are closed with a figure-eight 0 absorbable suture, the skin is approximated, and the Foley catheter (if used) is removed.

Transabdominal Preperitoneal Repair

A TAPP repair for recurrent inguinal hernia is shown in the video below.Laparoscopic repair of recurrent inguinal hernia: TAPP. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Laparoscopic access and port placement

One of the main criticisms of the TAPP procedure is the potential for intra-abdominal injuries. Accordingly, safe laparoscopic access is an essential initial step. A number of techniques, both open and closed, have been described. An excellent method of obtaining laparoscopic access at the umbilicus is the umbilical stalk technique (see the video below). [97]Laparoscopic inguinal hernia repair: TAPP. Umbilical stalk technique for obtaining laparoscopic access.

An infraumbilical incision is made, through which the subcutaneous tissues are dissected bluntly and the umbilical stalk is grasped with Kocher clamps and retracted upward. Fascia inferior to the umbilical stalk is then grasped with a second pediatric Kocher clamp, and the fascia is incised between the two clamps in a transverse fashion with a No. 15 blade scalpel. A Kelly clamp is gently placed through the incision to ensure that the peritoneal cavity has been entered.

At this point, a 5-mm trocar is placed, and the abdomen is insufflated. A 5-mm 30° scope is then placed through the trocar, allowing the peritoneal cavity to be viewed.

Two lateral 5-mm trocars are placed at the level of the umbilicus and lateral to the rectus at approximately the midclavicular line. It is important that the lateral ports not be placed too far inferiorly; a large preperitoneal pocket must be made to place the mesh, and the peritoneal flap can be hard to visualize if the port is placed too low. Care must also be taken to avoid the epigastric vessels during the placement of these trocars. The 5-mm trocar initially placed at the umbilicus is then upsized to an 11-mm trocar to facilitate entry of a large mesh prosthesis.

After ports are established, diagnostic laparoscopy of the entire abdomen is necessary to rule out other pathology or contraindications for surgery. Evaluation of the pelvis should follow. It is easy to identify hernia defects and to determine whether they are direct or indirect defects.

As a rule, the operating surgeon stands opposite the side of the hernia and operates using both hands, one for the umbilical trocar and the other for the trocar on his or her side of the table (ie, the side opposite the hernia defect). The assistant places the 5-mm 30° camera through the 5-mm trocar on the side of the hernia defect. If bilateral inguinal hernias are present, the surgeon and assistant first approach one side in this manner and then switch sides to repair the contralateral hernia.

Although the approach described above is preferred by the authors, it should be kept in mind that different approaches to port placement and camera location can be employed, depending on the assistant (who may be a resident, a surgeon, or a surgical technologist assistant) and his or her ability to assist with the operation and run the camera.

Obtaining an appropriate laparoscopic view during all portions of the TAPP procedure can be very difficult for the person controlling the camera and often requires considerable skill and experience. It is important, especially during the learning curve, that the camera operator/assistant have some previous experience with using a 30° camera.

Dissection

The procedure should always begin with careful inspection of the anatomy of the pelvis and bilateral groins (see the video below).Laparoscopic inguinal hernia repair: TAPP. Inspection of inguinal anatomy and identification of key structures.

The following key structures should be identified:

  • Median and medial umbilical folds
  • Lateral umbilical folds and epigastric vessels (see the first image below)
  • Vas deferens and spermatic vessels (see the second image below)
  • Iliac vessels
  • Hernia defect (direct or indirect) (see the third image below)
Laparoscopic inguinal hernia repair: TAPP. InferioLaparoscopic inguinal hernia repair: TAPP. Inferior epigastric vessels running up abdominal wall. These vessels help distinguish indirect from direct inguinal hernia.
Laparoscopic inguinal hernia repair: TAPP. Normal Laparoscopic inguinal hernia repair: TAPP. Normal anatomy of left inguinal region in male, with testicular vessels and vas deferens entering medially.
Laparoscopic inguinal hernia repair: TAPP. Right iLaparoscopic inguinal hernia repair: TAPP. Right indirect inguinal hernia.

After the anatomy is identified, laparoscopic scissors are used to make a small incision in the peritoneum at (or just lateral to) the medial umbilical ligament, just below the umbilicus (see the videos below).Laparoscopic inguinal hernia repair: TAPP. Cutting of peritoneum and dissection of pubis.

This incision is then extended laterally to the ASIS with scissors (see the image below). A common mistake is to make this incision too inferiorly. Special attention is required to keep the incision superior to the potential spaces for both direct and indirect hernia defects. The peritoneal flap must be extended far enough cephalad to ensure that it can cover the mesh and completely exclude it from the peritoneal cavity.

Laparoscopic inguinal hernia repair: TAPP. Sharp dLaparoscopic inguinal hernia repair: TAPP. Sharp dissection to take down peritoneum for access to inguinal region.

Next, the peritoneum is bluntly dissected away from the abdominal wall with blunt laparoscopic graspers. This is best done by grasping the edge of the peritoneal flap with one instrument and retracting superiorly and posteriorly while making an upward sweeping motion with the other instrument to sweep away the tissue of the posterior abdominal wall. The result should be an avascular plane, which is first carried down along the medial border of the flap until the pubis is identified and then dissected laterally in the same fashion.

Management of hernia sac

Before dissection of the hernia sac, the following important structures should be identified:

  • Pubic symphysis
  • Cooper ligament
  • Iliopubic tract

During the dissection, care should be taken to identify the triangle of doom, which contains the external iliac vessels and is bounded by the vas deferens medially and the gonadal vessels laterally. If the hernia sac is not reduced in conjunction with the dissection of the peritoneal flap, it can usually be reduced by means of gentle traction on the peritoneal attachments within the defect (see the video below).Laparoscopic inguinal hernia repair: TAPP. Reduction of indirect hernia with gentle traction.

The spermatic cord is then skeletonized by means of careful dissection. Once the cord structures have been clearly identified, any peritoneum of an indirect component is identified, separated from cord structures, and reduced. If there is a long indirect sac, the sac can be transected. It is essential, however, to minimize the risk of injury by first identifying the cord structures and reducing any peritoneal contents of the sac (see the images below).

Laparoscopic inguinal hernia repair: TAPP. ReductiLaparoscopic inguinal hernia repair: TAPP. Reduction of hernia sac and lipoma with upward traction.
Laparoscopic inguinal hernia repair: TAPP. DissectLaparoscopic inguinal hernia repair: TAPP. Dissection of remaining hernia sac by blunt dissection using traction and countertraction.
Laparoscopic inguinal hernia repair: TAPP. ReductiLaparoscopic inguinal hernia repair: TAPP. Reduction of hernia, showing hernia defect.
Laparoscopic inguinal hernia repair: TAPP. EvaluatLaparoscopic inguinal hernia repair: TAPP. Evaluation of peritoneum to ensure that entire hernia sac has been reduced.

Complete dissection of the pubis should be carried out to facilitate placement of the mesh prosthesis. The Cooper ligament should be cleared of preperitoneal fat and identified completely, and the musculoaponeurotic arch of the transversus abdominis should be cleared to approximately 2 cm superior and lateral to the internal inguinal ring.

Placement and fixation of mesh

After dissection and hernia reduction, the mesh prosthesis is placed in the extraperitoneal space. The authors typically use a piece of lightweight polypropylene mesh that is approximately 12 × 16 cm; this can be trimmed as necessary to fit the potential space. The mesh is rolled longitudinally and introduced with a grasper through the 11-mm trocar. It is then spread in the peritoneal cavity and positioned with two graspers (see the video below).Laparoscopic inguinal hernia repair: TAPP. Mesh placement.

Early in the learning curve, the surgeon may find it difficult to position the mesh appropriately in the preperitoneal space. To facilitate proper placement, the corner of the mesh that is to rest on the pubic bone can be grasped with a blunt grasper and placed through the trocar while the surgeon’s other hand holds the opposite corner of the mesh outside the trocar.

With one hand, the surgeon uses a grasper to push the mesh in and places the grasper on the pubic bone. With the other hand, he or she uses a blunt grasper placed through the 5-mm trocar to help position the mesh in the preperitoneal space. In the course of this process, it is important to use both hands and always hold the mesh in place in one area while pushing or pulling the mesh in the other direction. If the mesh becomes tangled or turned around, it is sometimes quicker and easier to remove it and start over.

In cases where placement of a flat sheet of polypropylene mesh proves challenging, a potential solution is to consider one of the preformed polypropylene meshes that have a right side and a left side; these are generally easier to place. When positioned correctly, the mesh should cover the direct, indirect, and femoral spaces for a potential hernia.

Once proper positioning has been confirmed, the mesh is anchored into place with a 5-mm laparoscopic tacking device. A common approach is to place two tacks in the pubis or Cooper ligament and two tacks on the anterior abdominal wall, medially and laterally, for fixation (see the video below).Laparoscopic inguinal hernia repair: TAPP. Mesh fixation.

If absorbable tacks are being used, they may have to be placed in the Cooper ligament rather than the pubis; some absorbable tacks may not penetrate the pubic bone. Although it can be tempting to place more tacks in an effort to guarantee that the mesh will be adequately secured, the temptation should be resisted; the use of too many tacks has been associated with postoperative pain. [63]

Once the mesh is fixed to the pubis or Cooper ligament, it is spread out laterally to remove any folds. Placement of the anteromedial and anterolateral tacks is done with a bimanual technique, in which the surgeon places one hand on the outside of the abdominal wall and applies pressure so that he or she can feel the tacking device and ensure proper placement above the iliopubic tract at a perpendicular angle. Avoiding tack placement posterior to the iliopubic tract helps avoid damage to the neural structures located below in the triangle of pain.

Port removal and closure

After the mesh is in place, the previously created peritoneal flap is lifted with graspers and tacked (or sutured) to the abdominal wall. To avoid injury to important structures, the same anatomic landmarks as in mesh placement and fixation are used (see the image below).

Laparoscopic inguinal hernia repair: TAPP. ClosureLaparoscopic inguinal hernia repair: TAPP. Closure of peritoneum over inserted mesh; this may be done with sutures or tacks.

Closure of the peritoneum with titanium tacks has been a common practice, but many surgeons are switching to absorbable tacks. Starting laterally, the peritoneal flap is tacked with the bimanual technique of exerting external pressure on the abdominal wall to confirm that the fixation device is placed at a right angle (see the video below). The peritoneum can also be repaired with sutures, but this requires expertise in laparoscopic suturing.Laparoscopic inguinal hernia repair: TAPP. Tacking of peritoneum.

After peritoneal closure, the ports are removed under direct vision, and the fascial defect at the 11-mm port is closed with a 0 polyglactin suture, either laparoscopically or by means of an open technique. In the laparoscopic approach, the fascial defect at the 11-mm port can be closed by using a suture passer under direct laparoscopic vision. All skin incisions are then closed with 4-0 poliglecaprone subcuticular sutures and the dressing of choice.


Medication Summary

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Local Anesthetics

Class Summary

Local anesthetic agents are used to increase patient comfort during the procedure.

Lidocaine and Epinephrine (Lignospan Forte, Xylocaine with Epinephrine)

Lidocaine is an amide local anesthetic used in a 0.5-1% concentration in combination with bupivacaine (50:50 mixture). This agent inhibits depolarization of type C sensory neurons by blocking sodium channels. Epinephrine prolongs the duration of the anesthetic effects from lidocaine by causing vasoconstriction of the blood vessels surrounding the nerve axons.

Bupivacaine (Marcaine, Sensorcaine)

Bupivacaine 0.25% may be used in combination with lidocaine plus epinephrine (50:50 mixture). It decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization, blocking the transmission of nerve impulses.

General Anesthetics

Class Summary

After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam or lorazepam dose is administered.

Propofol (Diprivan, Fresenius Propoven)

Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Propofol IV produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes, following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.

Thiopental

Thiopental is a short-acting barbiturate sedative-hypnotic with rapid onset and a duration of action of 5-20 minutes. Like methohexital, it is most commonly used as an induction agent for intubation. To use thiopental as a sedative, titrate in dosage increments of 25 mg (adjust to lower dose in children).

Antibiotics

Class Summary

Typically, a single dose of a cephalosporin is administered by the anesthesiologist before the skin incision.

Cefazolin

Cefazolin is a first-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting bacterial growth. It is used for the treatment of infections caused by gram-positive cocci (except enterococci).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Class Summary

These agents have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase (COX) activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Diclofenac (Voltaren-XR, Cataflam, Zipsor, Cambia)

Diclofenac inhibits prostaglandin synthesis by decreasing COX activity, which, in turn, decreases formation of prostaglandin precursors.

Ibuprofen (Advil, Ultraprin, I-Prin, Motrin IB)

Ibuprofen is the drug of choice for patients with mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Sulindac (Clinoril)

Sulindac decreases the activity of COX and, in turn, inhibits prostaglandin synthesis. Its action results in the decreased formation of inflammatory mediators.

Naproxen (Anaprox, Aleve, Naprosyn, Naprelan)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme COX, which results in prostaglandin synthesis.

Meloxicam (Mobic)

Meloxicam decreases COX activity and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Flurbiprofen

Flurbiprofen may inhibit COX, thereby, in turn, inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who experience moderate to severe pain.

Acetaminophen and codeine (Tylenol #3)

This combination is indicated for mild to moderate pain.

Acetaminophen (Tylenol, Aspirin-Free Anacin, Cetafen, Mapap Extra Strength)

Acetaminophen is the drug of choice for the treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, as well as in those with upper GI disease or who are taking oral anticoagulants.

Hydrocodone bitartrate and acetaminophen (Vicodin ES, Lortab, Lorcet Plus, Norco, Maxidone)

This agent is indicated for the relief of moderately severe to severe pain.

Tramadol (Ultram, Ryzolt)

Tramadol is an analgesic that probably acts over monoaminergic and opioid mechanisms. Its monoaminergic effect is shared with tricyclic antidepressants. Tolerance and dependence appear to be uncommon.

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