The peritoneal incision is started 4–5 cm above the internal ring. We include the transversalis fascia in the flap thereby exposing the rectus muscle in the midline. This is carried laterally to the ASIS (anterior superior iliac spine) (Fig. 7.3).

Take care to avoid injury to the inferior epigastric vessels and dissect bluntly to keep them elevated anteriorly along the rectus muscle .

If performing a bilateral hernia repair, we recommend extending the peritoneal incision across the midline to the contralateral ASIS and dissecting out the entire preperitoneal space to provide superior visualization and room. Some surgeons advocate separate peritoneal incisions and dissections as it is felt this makes closure simpler, although, by starting the closure in the midline and moving laterally is not problematic and is at the surgeons’ discretion, provided dissection is sufficient to allow for midline mesh overlap. Bringing down the entire preperitoneal flaps facilitates mesh placement in the setting of bilateral inguinal hernias.

It is important to not only get through the peritoneum but through the transversalis fascia as well to dissect in the areolar plane between the transversalis fascia and the transversus abdominus muscle. In up to 20% of patient, the muscle will be fused to the fascia laterally and will have to be separated from the transversalis fascia to maintain the proper plane.

For a unilateral hernia, the extent of dissection will be medially 1–2 cm past symphysis pubis to the contralateral side, laterally to the ASIS, and caudally 5 cm below the ileopubic tract.

At the medial portion of the dissection, identify the pubis symphysis/pubic tubercle then follow this laterally to Cooper’s ligament, which is then followed several centimeters inferolaterally to clear off the overlying tissue.

Be aware of the “corona mortis ” in this area, a crossing vein between the iliac vein obturator veins. Leave undisturbed or carefully divide with electrocautery. Unintentional disruption can lead to troublesome bleeding (Fig. 7.4).

Medially, look for direct defects. If present, reduce with traction and electrocautery. Lipomas in this area should be excised. If a large direct hernia defect is present, the transversalis fascia can be imbricated to reduce the incidence of postoperative seroma [2], though this is controversial and may result in nerve entrapment (Fig. 7.5).

Identify the indirect hernia sac and initiate the dissection laterally. The spermatic vessels and cord structures can be identified in this area and reduced inferiorly. Continue to reduce the indirect hernia sac at the level of the ring with usage of electrocautery as necessary once clear planes have been established to reduce risk of injury to cord structures (Fig. 7.6).

One should be able to get completely around the sac; this should be done to further isolate off the cord structures (Fig. 7.7) .

Avoid creating peritoneal defects onto the sac; however, these can be repaired at the conclusion of the dissection with a 3-0 vicryl suture.

In situations where reduction of the hernia sac is difficult, an additional 5 mm port may be placed in the upper abdomen on the patient’s right or left depending on the comfort of the bedside assistant. The assistant can apply constant traction to the hernia sac while the surgeon works to reduce it off the cord.

Complete reduction of the hernia sac is possible in most cases and recommended whenever it is feasible. This does not appear to substantially increase the risk of hematomas or testicular ischemia [2].

In situations where the hernia sac is quite large and redundant, the resulting defect is often quite small. To perform high ligation, it is preferable to establish a window anterior to the cord structures prior to division to ensure their safety. After fully encircling the sac and ensuring that the cord structures are isolated, the sac can be divided at the level of the internal inguinal ring. The distal portion is left open while the proximal portion is ligated. There is a higher risk of a postoperative hydrocele when leaving the distal portion of the sac so complete reduction is recommended when possible but high ligation is a good alternative when necessary.

Other tips include the following: 1. The peritoneal sac should be retracted completely off of the cord structures back to the level of the peritoneum, approximately mid psoas laterally and to the iliacs medially (Fig. 7.7).

2. Cord lipomas should be fully reduced and excised if they are encountered as this can mimic a hernia recurrence postoperatively.

3. Round ligament in females is typically left intact but can be taken if needed. There is some thought that transection increases pelvic floor dysfunction.

Overall, you should define the “critical view ” in the setting of laparoscopic inguinal hernia: the peritoneal flap is completely reduced, cooper’s ligament is exposed, the direct space has been explored, and the cord or round ligament can be seen entering the internal ring. All lipomas have been reduced as well.

Mesh is typically placed prior to docking into the abdomen to aid in efficiency. It is placed through the midline trocar (usually 12 mm); however, it is possible to slowly advance it through an 8 mm, though this may result in tearing or disfigurement of the mesh.

The mesh chosen should be a monofilament, have a pore-size of at least 1.0–1.5 mm, and have a tensile strength of >16 N/cm [2].

Polypropylene mesh (Bard © 3Dmax) is our preference. The shape is helpful with orientation, placement, and to reduce the need for anchoring. Large (10.8 × 16 cm) is generally utilized. X-Large (12.4 × 17 × 3 cm) may be preferable with a large hernia defect or in large patients. Some practices have transitioned to self-gripping polyester mesh for which we have limited experience but feel that it can be safe and may have the benefit of not requiring fixation.

There was previously a tendency by surgeons performing a laparoscopic repair to cut a slit in the mesh to allow cord structures to pass. This may however lead to recurrence and also scarring and pain associated with the cord structures, potentially with testicular ischemia. There does not appear to be any increased adverse occurrences associated with leaving the mesh intact and that is our recommended practice for the robotic platform.

There is ample evidence to support equal recurrence rates comparing fixation vs. non-fixation of mesh with lower incidence of chronic pain after non-fixation. However, non-fixation was frequently performed in hernias <3 cm; therefore, it is recommended to fixate mesh with hernia defects>3 cm [2]. This may be particularly true in the case of direct defects. An advantage to the robotic platform is the ability to place sutures (rather than utilizing a tacking device). We generally place two 3-0 vicryl simple interrupted sutures medially in the rectus muscle and 1 laterally, superior to the ASIS, into the transversus musculature. No sutures or tacks are placed into the midline bony or ligamentous structures. As with the laparoscopic approach, it is imperative to avoid fixation inferior to the iliopubic tract to avoid risks associated with triangle of pain and triangle of doom. Fibrin glue is an acceptable alternative for mesh fixation, which may result in lower chronic pain rates [2].