What are the key principles or golden rules for Minimally Invasive Surgery (MIS) hernia repair?

10 Golden Rules for MIS Hernia Repair

The 10 golden rules for safe minimally invasive surgery (MIS) hernia repair are based on achieving the critical view of the myopectineal orifice (MPO) and understanding the posterior groin anatomy through the inverted Y and five triangles concept, which together provide a systematic framework for safe repair regardless of technique (TAPP, TEP, ETEP, or RTAPP). 1

Rule 1: Achieve the Critical View of the MPO

• The critical view of the MPO must be obtained before mesh placement, analogous to the critical view of safety in cholecystectomy. 1
• This requires complete visualization of all anatomical structures and clear identification of the hernia defect boundaries. 1

Rule 2: Understand the Inverted Y and Five Triangles Anatomy

• Master the posterior groin anatomy by identifying the inverted Y (formed by the vas deferens and gonadal vessels) and the five essential triangles: triangle of doom, triangle of pain, lateral triangle, medial triangle, and femoral triangle. 1
• This anatomical framework prevents vascular and nerve injuries during dissection. 1

Rule 3: Manage Obturator Fat Appropriately

• Do not remove normal fat plugs from the obturator canal, as this is unnecessary and increases operative risk without benefit. 2
• Only address true hernias through the obturator space. 2

Rule 4: Complete Dissection of the Hernia Sac

• Perform adequate dissection to fully reduce all hernia contents and identify the entire defect perimeter. 1
• For indirect hernias, dissect the sac completely from cord structures to prevent recurrence. 1

Rule 5: Transect the Round Ligament When Necessary (Females)

• In female patients, transection of the uterine round ligament 1 cm proximal to the deep ring facilitates adequate dissection and does not appear to cause complications. 2
• This maneuver improves visualization and mesh placement in female inguinal hernias. 2

Rule 6: Handle Large Indirect Sacs Safely

• For huge indirect sacs, transection is safer than over-dissection of cord structures to prevent vascular injury and testicular complications. 2
• Whether to completely dissect or abandon the distal sac remains debated, but safety takes priority over theoretical seroma prevention. 2

Rule 7: Identify and Remove Cord Lipomas

• Any retroperitoneal structure traversing the internal ring functions as a hernia; failing to identify and remove lipomas will result in recurrence. 2
• Cord lipomas must be completely excised from the preperitoneal space. 2

Rule 8: Ensure Adequate Mesh Coverage

• Mesh must overlap the defect by at least 1.5-2.5 cm in all directions to prevent recurrence. 3, 4
• For defects larger than 3 cm or when tension-free primary closure is difficult, mesh reinforcement is mandatory. 3
• Synthetic mesh is standard in clean surgical fields and associated with significantly lower recurrence rates (3.2% vs 27.2% with biological mesh). 5

Rule 9: Avoid Critical Anatomical Danger Zones

• Never place tackers or sutures in the triangle of doom (containing external iliac vessels) or triangle of pain (containing lateral femoral cutaneous nerve, femoral branch of genitofemoral nerve, and femoral nerve). 1
• For diaphragmatic hernias, tackers should never be used near the pericardium due to cardiac complication risk. 3

Rule 10: Close the Peritoneum Properly in TAPP

• In TAPP repairs, the peritoneum should preferably be closed with suture rather than tackers to reduce chronic pain and ensure complete coverage of the mesh. 2
• Suture closure provides more reliable peritoneal coverage and reduces mesh-related complications. 2

Key Technical Considerations

Surgical Field Classification and Mesh Selection

• In clean/clean-contaminated fields, use synthetic mesh regardless of defect size for superior long-term outcomes. 6
• For contaminated/dirty fields with defects <3 cm, perform primary repair without mesh. 6
• For contaminated/dirty fields with defects ≥3 cm, biological mesh is preferred when available. 6

Approach Selection

• Laparoscopic approaches (TAPP/TEP) are preferred in stable patients, offering lower wound infection rates, reduced analgesic requirements, early return of bowel function, and shorter hospital stays. 5
• MIS repair has excellent safety profile with in-hospital mortality of 0.14% in stable patients. 3
• In unstable patients with complicated hernias experiencing severe sepsis or septic shock, open management (laparotomy) is mandatory to prevent abdominal compartment syndrome. 5, 3

Common Pitfalls to Avoid

• Inadequate mesh overlap (<1.5 cm) is a primary cause of recurrence. 3
• Incomplete dissection leaving residual hernia sac or lipoma leads to recurrence. 2, 1
• Tacker placement in neurovascular danger zones causes chronic pain and vascular injury. 1
• Using absorbable sutures for primary repair increases recurrence risk. 4