Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report

From October 1990 to December 1991, we performed 61 laparoscopic preperitoneal mesh repairs of inguinal hernias on 52 patients, including 22 direct, 38 indirect, and one femoral hernias. The laparoscopic technique employs the same principles as open preperitoneal mesh repair of replacing and reinforcing attenuated transversalis fascia. After entering the peritoneal cavity through the umbilicus, the preperitoneal space is entered by excising the hernia sac. The preperitoneal space is bluntly dissected and the transversalis fascia exposed. For a direct or recurrent hernia, the defect in the transversalis fascia is closed with a pursestring or running suture without tension. For an indirect hernia, the internal ring is tightened with an interrupted suture. Next a piece of mesh approximately 2.5 x 4.5 inches is trimmed to fit over the internal ring, the testicular vessels, and spermatic cord laterally, Hesselbach's triangle medially, and Cooper's ligament inferiorly, which covers potential sites for a new hernia or recurrence. The mesh (Prolene or Marlex) is then sutured with 3-0 vicryl to the transversalis fascia and transversus abdominis aponeurosis superior-medially, to the iliopubic tract or Cooper's ligament inferiorly, and to the transversalis fascia and transversus abdominis lateral to the internal inguinal ring. Upon completion of the tensionless repair, the peritoneum is reapproximated. Compared with the open procedure, laparoscopic repair reduces postoperative pain and shortens convalescence. No lifting restrictions are imposed on the patient. We have had three minor complications and no recurrences to date, but follow-up is too short to make firm conclusions.