Laparoscopic TAPP for bilateral inguinal hernia

This video, recorded live during a surgical course, demonstrates the TAPP approach to bilateral hernia repair. Dr. Joel Leroy performs the repair using two separate meshes, one side at a time. This procedure is recommended to a general surgical audience. The author uses a 3-trocar approach with a 0-degree 10mm optical scope. Exploration reveals some vivid landmarks, including abdominal wall adhesions from a previous appendectomy. The midline of the urinary bladder, umbilical ligament, vas deferens duct crossing behind the umbilical artery from behind —a key landmark the author will use during dissection of the peritoneum — and spermatic vessels all come into view. The direct hernia is visible between the epigastric vessels, retracted medially, and the umbilical ligament, retracted into the sac. When the author tries to reduce the sac, pressure pushes it back.

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Laparoscopic TAPP for bilateral inguinal hernia

Authors

Abstract

This video, recorded live during a surgical course, demonstrates the TAPP approach to bilateral hernia repair. Dr. Joel Leroy performs the repair using two separate meshes, one side at a time. This procedure is recommended to a general surgical audience.
The author uses a 3-trocar approach with a 0-degree 10mm optical scope. Exploration reveals some vivid landmarks, including abdominal wall adhesions from a previous appendectomy. The midline of the urinary bladder, umbilical ligament, vas deferens duct crossing behind the umbilical artery from behind —a key landmark the author will use during dissection of the peritoneum — and spermatic vessels all come into view. The direct hernia is visible between the epigastric vessels, retracted medially, and the umbilical ligament, retracted into the sac. When the author tries to reduce the sac, pressure pushes it back.

Mots-clés

TAPP, bilateral hernia repair, separate meshes

Type de vidéo

Vidéo chirurgicale

Durée

15'30''

Publication

2007-09

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2173.htm

Laparoscopic TAPP for bilateral inguinal hernia

1. Trocar placement and exploration 00'15''

This is a bilateral TAPP. We had doubts about the bilateral hernia but that has been confirmed by the first exploration we did. I put three trocars in, one is the 12mm optical trocar situated at the umbilicus, I will introduce the mesh through this one. Two other trocars located at the crossing of the horizontal line at the level of the umbilicus and right and left mid-clavicular line, I will work with both of these. First, we did the pneumoperitoneum and found the inguinal hernia on the right side and suspicion of a hernia on the left side. It is not a complete hernia but certainly the beginning of one. We can reduce this hernia easily. The landmarks are the umbilical artery; crossing this artery posteriorly there is the vas deferens duct, spermatic vessel laterally and iliac vessels between, this is the triangle of doom. Laterally the triangle of pain made of the spermatic vessels and the inguinal ligament. I will now show you the opening of the preperitoneal space. I do a tattoo.

2. Right peritoneal incision 02'30''

I have to do the horizontal incision, it is to avoid doing an oblique incision. After we have done the incision of the peritoneum, we grasp it to use opening by the pressure of the pneumoperitoneum and of the gas. This arch appears and I will incise on this arch, this is the plicature of the peritoneum due to the traction. I have to incise in such a way to have a larger opening than you do for the TAPP approach. I complete this with a vertical incision of this peritoneum. This is a L-shaped incision.

3. Preperitoneal dissection 03'37''

I now need to find the plane whilst staying close to the peritoneum to be sure that we safeguard completely the retroperitoneal structures, and particularly the nerve. I am using traction, so I am beginning on the right, I dissect until I reach the spermatic sheet. This is the lateral wing of the spermatic sheet and we can see the spermatic vessels here that we can see behind there. I now do a medial dissection, I will separate the peritoneum of the hernia sac when we have a direct hernia; when we have an indirect one we free the sac from the spermatic cord at the end. We have now reached the symphysis, the iliopubic branch, this is the left one, this is the right one. We now reduce the hernia sac. We pull on the sac we have the epigastric vessels coming. The direct hernia is reduced slowly. This is the transversalis fascia, I am pushing on it, I’m pulling on the hernia sac. We now have to free the peritoneum from the spermatic cord to do the parietalisation. I have now finished dissecting the right side and we will do the left side. See the spermatic vessels, see the peritoneum, and the transversalis fascia, the rectus muscle, and the transversalis fascia medial to the epigastric vessels.

4. Mesh placement 06'32''

For a bilateral hernia, why not put in one big mesh across both sides? I do that normally but today I will put two meshes overlapping medially. We don’t have any danger to have hernia on the midline because the difference with open is that there is no incision on the midline, so we can imagine that overlapping on the midline is enough. Because it is a direct hernia we have to cover largely medially and posteriorly to the iliopubic branch. I continue on this side. I know that you’ve always put these staples laterally. Do you have any problems with nerve damage because of the staples? If you fix above this line and not laterally, there is a limited risk of pain due to the fixations. Normally it is finished for the lateral side, I go to the other side and change my position by going to the right side of the patient because we have a doubt before the start of the procedure, we put the patient’s both arms alongside the body. Normally when I put a large mesh I dissect bilateral first, same landmark.

5. Left peritoneal incision 08'50''

Anterior superior iliac spine to find where it is. I begin medially because I am a right-handed surgeon. I will begin at this level by cutting the peritoneum first. There is a danger at this level when you are too high, there is a fixation to the fascia, the Douglas arch and difficulty to open.

6. Preperitoneal dissection 09'40''

As you have seen, you incise largely above to avoid opening the peritoneum, we are now in the right plane, these are the spermatic vessels. Would it really help if you placed the patients head down in the Trendelenburg position? We use a small Trendelenburg to expose but not too much. We see the vas deferens duct, these are the spermatic vessels, iliac artery, iliac vein, internal ring of the inguinal canal, this is the spermatic cord with the vas deferens, the spermatic vessels, the lateral wing of the spermatic sheet; I think it’s enough. Not much of a hernia on the side really? No but we have a direct hernia on the right, we have the beginning of a direct hernia on the left, this is not a congenital hernia.

7. Mesh placement 11'25''

The risk is to have a contralateral hernia on the side we haven’t operated on, we are putting the mesh to prevent hernia in the future. I’m now introducing the mesh. I unwrap it from medial to lateral, maintaining it medial with my ipsilateral forceps. We control and remove the trocar, maintaining the instrument inside to make sure there is no bleeding, we can push back eventually. We are leaving the camera in as the carbon dioxide comes out to show the importance when doing the TAPP of closing the peritoneum completely because there is a possibility of an internal hernia if it is not fixed either by suture or by tack, as it comes down if it’s not fixed properly you can get a defect. That’s for the CO2 in the extraperitoneal space. What can happen, the bowel exits through the umbilical port. When removing your trocar, the danger is to have incarceration of bowel or omentum. I have exsufflated before as you remember.