Anatomical landmarks and TAPP approach for right inguinal hernia

This video, recorded live during a surgical course, demonstrates the TAPP approach to unilateral hernia repair. A detailed discussion of the technique is presented by Dr. Joel Leroy. This procedure is recommended to a general surgical audience. The author carries out this transabdominal preperitoneal approach using 3 trocars: a 12mm (for mesh and camera), and two 5mm trocars. After exploration to assess the anatomy, the author proceeds to determine the landmarks. With the left trocar, he takes down adhesions from a previous appendectomy. Using low-energy coagulation, he carries out the vertical incision. The procedure continues as he carries out the dissection laterally and then places the mesh.

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Anatomical landmarks and TAPP approach for right inguinal hernia

Authors

Abstract

This video, recorded live during a surgical course, demonstrates the TAPP approach to unilateral hernia repair. A detailed discussion of the technique is presented by Dr. Joel Leroy. This procedure is recommended to a general surgical audience.
The author carries out this transabdominal preperitoneal approach using 3 trocars: a 12mm (for mesh and camera), and two 5mm trocars. After exploration to assess the anatomy, the author proceeds to determine the landmarks. With the left trocar, he takes down adhesions from a previous appendectomy. Using low-energy coagulation, he carries out the vertical incision. The procedure continues as he carries out the dissection laterally and then places the mesh.

Mots-clés

TAPP approach, unilateral hernia repair, peritoneal incision

Type de vidéo

Vidéo chirurgicale

Durée

13'45''

Publication

2007-09

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2175.htm

Anatomical landmarks and TAPP approach for right inguinal hernia

1. Trocar placement 00'34''

I will show you a TAPP. I will use 3 trocars, one 12mm trocar and two 5mm ones, we can also use 3mm trocars laterally. The 12-10mm trocar is used to introduce the mesh and the scope even if we can reduce the size of the scope. These are the different landmarks we will use to introduce our trocars, the pubis, the limit of the ribs before insufflation, after insufflation there is a big distance due to the distension of the abdominal wall; you have to imagine the landmarks after insufflation. The landmarks are the midline, right and left mid-clavicular line, anterior axillary line just at the limit of the right and left anterior superior iliac spine; after insufflation it is a little different, the horizontal line at the level of the umbilicus. As you can see, I have introduced the first trocar (number 1) just above the umbilicus, this is a 12mm One-step trocar. We introduced it using a mini-open technique, we do a very small incision of the aponeurosis and we introduce the sleeve in which we introduce the 12mm trocar. I have introduced it at the level of the crossing between the right mid-clavicular line and the horizontal line at umbilical level. A little below is the 5mm trocar (number 3) on the left.

2. Exploration 02'45''

I use a 0 degree, 10mm scope. This patient had an appendectomy so there are small adhesions to the abdominal wall, scars, and adhesions on the right side. On the midline, we have the urinary bladder, no urinary catheter and we have no defect on the left. This is a vertical anatomical structure, this is the umbilical ligament, we see it very well running to the umbilicus coming from the internal iliac artery. Vas deferens duct that crosses the umbilical artery behind. This will be the landmark we choose to dissect the peritoneum from the retroperitoneal structures. These are the spermatic vessels, both structures are running to the same direction, that is the internal inguinal ring that we can’t see because what we have is a direct hernia Nyhus IIIa located between the epigastric vessels we can’t see because they are probably retracted medially, and in between the umbilical ligament retracted into this sac. I will show you, we can reduce the sac like this but the pressure will push it. This is the triangle of Doom, with the iliac artery and iliac vein, this is a danger during the dissection, do not fix using staples in this structure. We have another triangle in which we have a second fix, this is the triangle of pain where we have nerves running on the muscles so we will not fix a mesh in this area and we will be careful during the dissection because the nerves are not too far. Normally I have to free the adhesion but I won’t do it since it’s not necessary in this case.

3. Peritoneal incision 05'30''

I have to find my landmark by opening the peritoneum only. You see my left hand is pulling, the problem in this case are the adhesions due to the appendicectomy. My assistant opened the tap of the ipsilateral trocar and I do a horizontal incision. I am using coagulation (very low energy) but the best may be to use division.

4. Preperitoneal dissection 06'28''

And I am doing a vertical incision, I am coming back laterally because I think it’s easier to do it first there except if you have adhesions. It is key to find the embryological plane. We only use 16 Watts to do the dissection, I am using a sharp dissection and when I have finished to free laterally, I have to do the medial dissection. I am now using my instrument as 2 fingers pulling and using traction counter-traction. I have dissected laterally and medially, this is a direct hernia so it is not so difficult to do. Now I am grasping the sac, pulling posteriorly and you will see a white structure, which is the transversalis fascia. This is the hernia sac reduced previously, this is the hernia defect and here is the transversalis fascia. Here the epigastric vessels, so this is an indirect hernia, I thought it was direct but the repair is similar because there is no posterior wall. The posterior wall of the inguinal canal is completely destroyed. It is a Nyhus IIIb hernia. The internal and external rings are completely in the same position and there is no obliquity of the inguinal canal. I now have to free the peritoneum from the spermatic cord, laterally to the vessels, medially to the vas deferens. It is an indirect hernia but I will do the same repair as for a direct hernia: I will reverse the transversalis fascia, I am doing the parietalisation of the spermatic cord. I have finished to dissect. I incise very high in order to avoid the curtain effect because you will have the flap falling in the field and you will not see very well. I will reverse the transversalis fascia, which is not usual for indirect hernias, with the danger that running anterior to the transversalis fascia, that is the posterior wall of the inguinal canal in this case, you have the vessels and nerves of the spermatic cord running.

5. Mesh placement 10'16''

Now to the mesh preparation. This is a polyester mesh, multifilament, this is the shape of the mesh; this is medial, lateral, inferior, superior and: 12, 15 and 8cm respectively. So we roll it from the lateral side to the medial one and from anterior to posterior. We will unroll it in the other direction. We keep half a centimeter free, I’m grasping the inferior edge and will introduce it in the optical trocar pushing into the preperitoneal space, and we maintain it and push it into position. I am fixing onto the Cooper’s ligament first and I’m going laterally towards the anterior superior iliac spine. I’m putting the mesh. Now it is fixed, and we will now close the gap. It is very important that the bottom part of the mesh does not lift up as he pulls this up, otherwise you can get recurrence underneath the mesh; so the mesh needs to sit easily without disturbance. As you see, I am overlapping. We have a small defect done during the dissection and I will use Maxon monofilament to close it. Here’s my method of knot-tying. One stitch on the Cooper’s ligament, you can do a running suture on the superior edge but without knots since it’s not necessary, it is only to build and maintain the mesh, preventing it from sliding.