Laparoscopic Transabdominal Preperitoneal
Inguinal Hernia Repair
Michael J. Rosen, MD
W hen considering a laparoscopic approach for repairing
inguinal hernias, the surgeon has several options. Ini-
tially laparoscopic repairs involved an intraperitoneal onlay
mesh. Using this technique, the surgeon placed a large piece of
mesh in an intraperitoneal position, similar to a laparoscopic
ventral hernia repair. This approach has largely been abandoned
secondary to high recurrence rates and the drawbacks of intra-
peritoneal mesh. The remaining two techniques include a totally
extraperitoneal (TEP) and a transabdominal preperitoneal
(TAPP) approach. The main difference between these two tech-
niques is the sequence of gaining access to the preperitoneal
space. In the TEP approach, the dissection begins in the preperi-
toneal space with a balloon dissector. In the TAPP approach, the
preperitoneal space is accessed after initially entering the perito-
neal cavity. Each approach has its own merits. Using the TEP
approach, the preperitoneal dissection is quicker, and the po-
tential risks of intraperitoneal visceral damage are minimized.
However, the use of dissection balloons can be costly, the work-
ing space is more limited, and in the case of prior preperitoneal
surgery or mesh the space may be impossible to create. Addi-
tionally, if large tears in the peritoneal flap are created during a
TEP, the potential working space can become obliterated neces-
sitating conversion to a transabdominal approach. For these
reasons, knowledge of a transabdominal technique is essential
when performing laparoscopic inguinal hernia repairs. The
transabdominal approach allows immediate identification of the
groin anatomy before extensive dissection and disruption of
natural planes. The larger working space of the peritoneal cavity
can make early experience with the laparoscopic approach safer
and easier. The TAPP is the preferred approach of the author and
will be described herein.
There are no absolute contraindications to laparoscopic
inguinal hernia repair other than the inability to tolerate gen-
eral anesthesia. Patients who have had extensive prior lower
abdominal surgery can require significant adhesiolysis and
may be best approached anteriorly. In particular patients
who have had a radical retropubic prostatectomy with the
preperitoneal space previously dissected can make accurate
safe dissection challenging.
Department of Surgery, University Hospitals of Cleveland, Case Western
Reserve School of Medicine, Cleveland, OH.
Address reprint requests to Michael J. Rosen, Assistant Professor of Surgery,
Department of Surgery, University Hospitals of Cleveland, Euclid Ave,
Cleveland, OH 44106. E-mail: Michael.rosen@uhhs.com
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2006.04.008
Preoperative
Routine use of Foley catheterization is not performed. The
patients are instructed to empty their bladder before entering
the operating room. A single dose of a first generation ceph-
alosporin is given and sequential compression devices are
applied. The patient is placed under general anesthesia, both
arms are tucked at the patients’ side, and the abdomen and
groin are sterilely prepped. The surgeon stands on the side
opposite the hernia and the first assistant stands on the ipsi-
lateral side of the hernia along with the scrub nurse. The lapa-
roscopic tower is positioned at the foot of the table (Fig. 1).
Trocar Positioning
The abdomen is accessed via an open Hasson technique
through an infraumbilical incision. The abdomen is insuf-
flated to 15 mmHg. A 5 mm 30 degree laparoscope is then
inserted and a general inspection of the abdominal cavity is
performed. The pelvic floor is evaluated and the pathology of
the inguinal anatomy is examined (Fig. 2). Two additional
5-mm ports are placed in line with the umbilicus and just
lateral to the inferior epigastric vessels. These trocars should
remain above the umbilicus to avoid interference with the
preperitoneal flap dissection. Additionally, placing these tro-
cars too far laterally can result in difficulty navigating instru-
ments across the abdominal viscera (Fig. 3). Using an angled
5-mm laparoscope, the surgeon can stand on the opposite
side of the hernia and use the middle trocar as a working port.
The camera operator uses the lateral 5-mm port ipsilateral to
the defect for visualization.
Peritoneal Flap Dissection
The patient is placed in a slight Trendelenberg position. The
dissection begins at the ipsilateral medial umbilical fold. The
preperitoneal flap is raised from a medial to lateral direction
using the curved scissors with monopolar cautery. It is impor-
tant to begin this dissection rather cephalad on the abdominal
wall to leave enough space for reduction of the hernia and place-
ment of an appropriately sized piece of mesh (Fig. 4). Addition-
ally, as the initial incision is carried laterally, one should avoid
the temptation to drift inferiorly toward the inguinal canal, again
compromising the eventual space necessary for mesh place-
ment. The proper incision carries transversely across the ab-
45
46 M.J. Rosen

Figure 1 Patient positioning and operating room setup for left inguinal hernia. Surgeon stands on opposite side of hernia
using middle and lateral trocar working ports. First assistant stands on ipsilateral side of hernia with camera. Arms are
tucked bilaterally at sides, with monitor at foot of bed.

dominal wall toward the anterior superior iliac spine. When
traversing across the plane, one must be cautious and avoid the
epigastric vessels. Achieving the appropriate dissection plane is
critical to the success of the operation. Although the dissection is
typically below the arcuate line there tends to be an attenuated
transversalis fascia that is adherent to the rectus muscle. The
appropriate plane is just superficial to the peritoneum. By grasp-
ing the inferior cut edge of the peritoneum and retracting ceph-
alad the preperitoneal space is created by gently pushing away
and dividing the loose filmy attachments (Fig. 5). The first struc-
Transabdominal preperitoneal inguinal hernia repair
Figure 2 Inguinal anatomy of the right side. Location of indirect and direct space in relation to the inferior epigastric
vessels.
ture identified is Cooper’s ligament. By sweeping down the blad-
der staying high on the anterior abdominal wall one eventually
encounters this white firm ligament. Even in unilateral hernias,
I routinely sweep the bladder far medially past the midline to
provide adequate mesh overlap. Cooper’s ligament is cleared off
laterally until a fairly constant crossing vessel is identified. This
so-called “aberrant” obturator vessel is present in over 75% of
patients. Next, the lateral dissection is begun. Unlike the medial
dissection plane which typically can be developed bluntly allow-
ing the preperitoneal fatty tissue to divide in its natural plane, the
appropriate plane for the lateral dissection is directly on the
peritoneum which can typically be quite thin. The lateral dissec-
tion is carried medially until the spermatic vessels and then the
vas deferens are encountered. One must use extreme caution
when using electrocautery in the preperitoneal space, as a loop
of intestine can be just below the peritoneal flap with energy
easily transmitted through the flap.
Dissection of Hernia Sac
At this point the hernia sac should be reduced (Fig. 6). If a
direct defect is encountered, the hernia contents are grasped
and the attenuated transversalis fascia is gently teased away.
If an indirect hernia is identified, the sac is likewise grasped
47
and retracted while bluntly sweeping off attachments to the
cord structures. Large chronic indirect sacs can be particu-
larly challenging. In cases where the hernia sac cannot be
completely reduced, it can be transected and either sutured
or closed with an endoloop leaving the distal end open. Any
cord lipoma typically located inferior and lateral to the cord
structures should be completely reduced to avoid potential
confusion as a recurrence. These lipomas do not need to be
resected and can be left in the preperitoneal space. Once the
hernia sac is completely reduced, the peritoneal flap should
be dissected at least 3 cm off the vessels and cord structures to
prevent any drag coefficient from allowing peritoneum to
sneak under the mesh, predisposing to recurrence. The up-
per flap of peritoneum is then grasped and retracted cephalad
to develop a larger pocket for the mesh.
Placement of Mesh
At least a 12 ⫻ 14 cm piece of polypropylene mesh is utilized.
We do not place a slit for wrapping around the cord struc-
tures as recurrences have occurred through these defects.
The mesh is grasped at the medial aspect. We do not roll the
mesh tightly as this just makes unraveling more difficult once
inside the patient. The mesh is brought in through the
48
Figure 3 Trocar positioning. Note two lateral ports are just lateral to the inferior epigastrics in line with the umbili-
cus.
10-mm trocar and tucked medially into the pocket. The su-
perior medial corner of the mesh is grasped and brought
anteriorly while the inferior instrument pushes the mesh
against the abdominal wall. While some groups advocate no
mesh fixation, we currently believe some form of mesh fixa-
tion is important to prevent migration. Once the mesh is
situated we place one tack in Cooper’s ligament. By only
placing one tack, the mesh can still be rotated to obtain ideal
lateral placement. However, the mesh will not migrate during
lateral retraction. We then place a spiral tack at the superior
lateral aspect of the mesh. It is critical that the tip of the tacker
can be palpated with the nondominant hand of the surgeon
through the anterior abdominal wall before deploying any
tacks. If the tacker can not be palpated it indicates that it is
likely below the iliopubic tract and therefore the lateral fem-
oral cutaneous, genital-femoral, or femoral nerve could be
entrapped. We then place one tack just lateral to the inferior
M.J. Rosen
epigastric and one at the superior medial border of the mesh.
Finally, another tack is placed in Cooper’s ligament (Fig. 7).
At the conclusion, the peritoneum is re-examined with par-
ticular concern over the vessels to ensure it is not encroaching
underneath the mesh. No tacks can be placed in the “triangle
of doom” bordered by the vas deferens medially and the
spermatic vessels laterally which contains the iliac artery and
vein.
Peritoneal Closure
The peritoneal flap is then secured to the anterior abdominal
wall. This can be completed with spiral tacks, staples, or
suturing. Any defects in the peritoneum should be closed.
Occasionally, the reduced hernia sac can be used to close
these defects. If a large hole in the peritoneum is created,
several maneuvers can aid closure. The peritoneal flap dis-
Transabdominal preperitoneal inguinal hernia repair 49

Figure 4 Dissection of peritoneal flap. The flap begins at the medial umbilical fold. Note the length above the inguinal
structures high on the anterior abdominal wall. Care is taken to avoid the epigastric vessels.

Figure 5 The inferior flap is grasped and retracted while the loose filmy attachments of the preperitoneal space are
dissected free. The medial dissection is completed clearly identifying Cooper’s ligament.
50 M.J. Rosen

Figure 6 The indirect hernia sac is carefully reduced off of the cord structures.

Figure 7 The mesh is secured to the anterior abdominal wall with spiral tacks. No tacks are placed below the iliopubic
tract.
Transabdominal preperitoneal inguinal hernia repair
section should be extended inferiorly to gain laxity for clo-
sure, the pneumoperitoneum pressures can be reduced to 8
to 10 mmHg to decrease tension, and the patient can be taken
out of the Trendelenberg position. For left sided defects, the
sigmoid colon can be released from its peritoneal attach-
ments. The umbilical port is closed with a single figure of
eight resorbable suture and the abdomen is desufflated.
Special Considerations
In cases of bilateral hernias, we use two separate pieces of
mesh that are secured together in the midline. The mesh is
placed in the first hernia but the peritoneum is not closed
51
until the other side is completed in case the mesh is acciden-
tally displaced.
In cases of prior preperitoneal hernia repairs, occasionally
the peritoneal flap is completely destroyed and in those cases
one can consider an onlay technique.
Postoperative Care
The patients are typically discharged home from the recovery
room. The patients must void before discharge as urinary
retention can be an issue especially in bilateral hernias. The
patients are instructed to avoid heavy lifting for several weeks
postoperatively. Patients are followed in the office at 2 and 6
weeks.