Understanding the Critical View of the Myopectineal Orifice (MPO) for Safe Minimally Invasive Surgical Inguinal Hernia Repair

Abstract

AbstractSafety and efficacy should be paramount in the mind of every surgeon when choosing a surgical approach. Minimally invasive surgical (MIS) inguinal hernia repair is no exception to this rule. The first laparoscopic inguinal hernia repairs were performed over 30 years ago, but acceptance of the technique was limited and accounted for only 10–15% of repairs. With the introduction of a robotic approach however the percent of MIS repairs increased rapidly and now accounts for almost 50% of inguinal hernioplasties [1]. With this rapid growth, we noted that many repairs were being performed without heeding the lessons learned from years of experience which had resulted in recurrence rates of less than 2% and an incidence of chronic pain less than open repairs. A schema unifying all MIS approaches that addresses the issues of safety and efficacy however was not published in a peer-reviewed journal until 2017 when it appeared in the Annals of Surgery [2]. The report outlined nine steps to achieve the critical view of the myopectineal orifice (MPO) of Fruchaud, a concept first introduced by Brian Jacob in 2015 and widely disseminated on the International Hernia Collaboration. Although there are several approaches to a MIS inguinal hernia repair including Transabdominal Preperitoneal (TAPP), Totally Extraperitoneal (TEP), Extended Totally Extraperitoneal (ETEP), Robotic Transabdominal Preperitoneal (R-TAPP), and Robotic Totally Extraperitoneal (R-TEP), they have a single underlying concept which promotes a safe and successful repair. The concept, the steps to achieving the critical view of the MPO, is based on the history of the development of MIS approaches and 1000 of MIS repairs. Each step was developed through careful study of the elements of the repair that contribute to success and those that result in complications or recurrences. It is important to understand that achieving the critical view of the myopectineal orifice of Fruchaud is not just the final view of the MPO but includes the steps of properly attaining the critical view and the steps required to complete the repair after the critical view is obtained. The order in which the steps are performed may need to be varied and will be illustrated but failing to complete every step increases the likelihood of complications and recurrence. This chapter goes through each step and how it should be applied no matter which MIS approach is utilized. Examples of how failing to achieve the critical view may cause the hernia repair to fail are also illustrated.