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Baur et al. Mini-invasive Surg 2021;5:27 https://dx.doi.org/10.20517/2574-1225.2021.28 Page 3 of 7

Surgical treatment of the medial hernial orifice
The medial hernial orifice is treated in large direct hernias (EHS M2 and M3) and/or if a considerable
weakness of the transverse fascia exists. The fascia transversalis is progressively plicated or sutured to the
iliopubic tract with a V-Loc suture; the suture is progressively performed concomitantly to the removal of
the fatty tissue before the fascia is blown outwards by the pressure of the pneumoperitoneum. This
approach takes some time (~5-8 min) due to the repetitive change of instruments (scissors/needle driver),
but allows a very precise handling of the tissue, eliminating the risk of injury to the spermatic vessels, the
cord, or nerve structures of the inguinal canal [Figures 1-3].

Surgical treatment of the lateral hernial orifice
In case of voluminous lateral hernias (EHS L2 and L3 with large hernia sac or lipoma) and in cases of scrotal
hernias, the inguinal canal is sealed via the inner inguinal ring using fibrin glue spray (Tiseel, usually 4 mL).
For this purpose, a specific flexible cannula is available [Figures 4-6]. This step increases the operative time
by approximately 3-5 min. The application of the fibrin glue has to be performed by a scrubbed-in assistant
familiar with the procedure.

Mesh fixation
In the authors’ institution, mesh fixation during robotic rTAPP is performed in all cases. The robotic
technology allows a minimally traumatic fixation of the mesh with four loosely knotted stitches with
resorbable suture material (Vicryl 3-0). The location of the four sutures is as follows: (1) Cooper’s ligament;
(2) fascia of the rectal muscle; (3) fascia of the transverse muscle; and (4) iliac fascia [Figures 7-9]. Even the
suture of the mesh to the iliac fascia in the location of the triangle of pain, can be very safely applied due to
the excellent visual control helping to protect and exclude the nerves that are localized just below this fascia
(i.e., N. cutaneous femoris lateralis and femoral and genital branches of the genitofemoral nerve) [Figure 8].

CONCLUSION
The treatment of the medial and lateral hernia orifice as part of endoscopic inguinal hernia treatment for
postoperative seroma prophylaxis seems to be reasonable, especially in the case of large hernias. The use of
DaVinci technology makes it thereby easier to apply the here presented techniques with utmost precision
and accuracy.

The described 4-point suture fixation technique for the rTAPP with absorbable sutures is safe, according to
the authors’ experience. Skipping fixation with the inherent risk of mesh migration and hernia recurrence
should not be advocated any more in times of robotic technology. A randomized evaluation of the described
techniques in terms of postoperative seroma formation, chronic pain, or recurrence has yet to be
performed. However, our preliminary, unpublished data concerning the strategies described above shows
no elevated rates of chronic pain, no recurrence, and a clear decrease of the incidence of seroma.