Correct and timely identification of the key structures in the lower anterior abdominal wall is critical for the safe laparoscopic repair of suprapubic hernias (Fig. 3-1). A careful preperitoneal dissection provides the needed landmarks for appropriate fixation to lessen the chance of postoperative recurrence.

Identification of the costal margins and xiphoid process provide the laparoscopic bounds of transabdominal fixation for repair of subxiphoid hernias (Fig. 3-2). Generous overlap of the mesh over the diaphragm helps provide adequate coverage of the fascial defect in lieu of superior fixation.

The lumbar triangle is defined superiorly and laterally by the latissimus dorsi muscle, medially by the external oblique muscle, and inferiorly by the iliac crest (Fig. 3-3). Weakness of the internal oblique and transversus abdominis musculature within the lumbar triangle leads to hernia formation (Fig. 3-4). An anterior abdominal approach can be used for laparoscopic repair, with proper patient positioning used to strategically expose the lumbar triangle.

For laparoscopic suprapubic and subxiphoid hernia repairs, the patient is placed in the supine position, with arms tucked and carefully padded. Laparoscopic lumbar hernia repair often requires elevation of the ipsilateral side for posterior transabdominal fixation (Fig. 3-5). Usual trocar placement for laparoscopic ventral hernia repair should suffice for initial approach and lysis of adhesions (see Chapter 2, Fig. 2-3). These parts are placed more medially than usual on the contralateral side of the hernia defect. Access to the suprapubic region and myopectineal orifice is facilitated through three trocars at the level of the umbilicus; two are placed just lateral to the linea semilunaris, and one is placed at the umbilicus.