Since the introduction of laparoscopic cholecystectomy in the late 1980s, video technology has continued to find new applications in the field of general surgery. Laparoscopic inguinal herniorrhaphy is touted by many to provide a minimally invasive approach to the most commonly performed general surgical procedure, possibly with a lower incidence of recurrence. Additionally, laparoscopic repair of an incisional hernia with synthetic mesh allows a tension-free procedure while potentially reducing the risk of complications such as wound and mesh infections by avoiding the use of large abdominal wall incisions through old surgical scars. The parapubic hernia is a rare form of incisional hernia resulting from the detachment of muscular attachments to the pubic bone. It is a diagnostic and therapeutic challenge that is often misdiagnosed and mismanaged. We have found the laparoscopic approach to the parapubic hernia to be a superior method of managing this often challenging condition.
A, Sagittal view of a parapubic hernia. B, Axial view of a parapubic hernia (a), similar to that seen from within the peritoneum. Note that this space is typically more anterior and medial relative to the location of a direct inguinal hernia (b) and an indirect inguinal hernia (c).
Schematic diagram demonstrating the positions of equipment and operators in laparoscopic parapubic herniorrhaphy.
Laparoscopic view of a typical parapubic hernia. Note the small bowel within the hernial sac.
The contents of the hernial sac are reduced and the defect in the fascia is sized using the open jaws of a 5-mm laparoscopic grasper.
The relationship between the borders of the hernia and the surrounding structures must be fully recognized. Note the dome of the bladder at the bottom of the figure. The absence of a catheter allows the expansion of the bladder and facilitates recognition of its borders.
A 2- to 3-cm circumferential margin is used for adequate reinforcement of the defect in the fascia.
Using a laparoscopic tacking device to secure an appropriately sized piece of synthetic mesh to the abdominal wall, the repair of the parapubic hernia is completed.
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