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.

Keywords: Inguinal hernia, Femoral hernia, Obturator hernia, Laparoscopic surgery, Laparoscope, Anatomy

Core tip: A high-quality hernia repair is seriously required for groin hernias. Surgeons should have good knowledge of the relevant anatomy (e.g., the preperitoneal space, myopectineal orifice, topographic nerves, regional vessels). Currently, laparoscopic surgery has therapeutic potential for hernioplasty, and laparoscopic transabdominal preperitoneal repair seems to be a powerful technique for use in adult patients. Both technical skill and anatomical familiarity are important for safe, reliable hernioplasty.