Brian P. Jacob, David C. Chen, Bruce Ramshaw, Shirin Towfigh (eds.) - The SAGES Manual of Groin Pain-Springer International Publishing (2016)

29. Prevention of Pain: Optimizing the Laparoscopic TEP…
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Three important lipomatous structures should be properly identified
during the laparoscopic repair of hernias: lipomas, a fatty spermatic
cord, and lymph nodes. Only the first of these should routinely be
removed to avoid “hernia” recurrence. Lipomas lie anterolateral to the
cord structures, are light yellow, have a thin capsule, are usually devoid
of accompanying vessels, and are easily dissected out of the internal
ring. A fatty cord, often seen in obese patients or in patients who have
undergone bariatric surgery, could be confused with a lipoma and partially
divided. A fatty structure with vessels running toward or from the
internal ring is usually a cord structure. Lymph nodes are usually positioned
posterior and lateral to the cord structures, are dark yellow, are
not easily displaced, and “bounce” when pushed with the dissector.
Lymph nodes should generally not be resected, to avoid bleeding and
nerve damage. The nerves usually run posterior to the lymph nodes. A
video showing these structures can be found online [ 13 ].
One meta-analysis concluded that the use of a low-weight mesh (less
material, large pores, some elasticity) lessens the risk of postoperative
pain, groin stiffness, and foreign body sensation, especially during the
first few months after laparoscopic inguinal hernia repair [ 14 ]. However,
another meta- analysis did not have the same findings [ 15 ]. Some studies
found that the use of a very-low-weight mesh increased the risk of recurrence,
probably because of the difficulty of fixing the mesh and the
tendency of the mesh to roll up. We use a mid-weight (45 g/m 2 ), largepore,
polyester mesh. A low- or mid-weight polypropylene mesh is also
suitable. The mesh should be at least 15–17 × 10–12 cm in size to completely
cover the myopectineal orifice of Fruchaud.
Many studies have reported that lack of fixation does not increase the
recurrence rate, reduces the cost of the procedure, and is associated with
less postoperative pain, but most of these studies focused on small hernias
(defects of