Laparoscopic TAPP inguinal hernia repair

This video demonstrates the steps in performing a TAPP (transabdominal preperitoneal) repair using a large mesh. The surgeon with the aid of artistic drawings demonstrate the key anatomic landmarks and dissection of the hernia sac and safe application of mesh and closure of peritoneal window. In this case the surgeon uses sharp dissection with scissors but the steps could well be completed bluntly with dissecting forceps.

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Laparoscopic   TAPP   inguinal   hernia   repair

Authors
J Leroy
Abstract
This video demonstrates the steps in performing a TAPP (transabdominal preperitoneal) repair using a large mesh. The surgeon with the aid of artistic drawings demonstrate the key anatomic landmarks and dissection of the hernia sac and safe application of mesh and closure of peritoneal window. In this case the surgeon uses sharp dissection with scissors but the steps could well be completed bluntly with dissecting forceps.
Catégorie
basic techniques
Mots-clés
inguinal hernia, laparoscopic, TAPP, right, mesh
Type de vidéo
Durée
08'00''
Publication
2003-05
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, May 2003;3(05).
URL: http://www.websurg.com/doi-vd01en1247e.htm

Laparoscopic   TAPP   inguinal   hernia   repair

1. Case presentation 00'13''
We present a laparoscopic trans-abdominal preperitoneal inguinal hernia repair. Before the era of laparoscopy, this was an unknown approach to inguinal hernia repair. The surgeon stands to the side opposite of the hernia, about the level of the shoulder of the patient. The assistant is across the table from the surgeon and the nurse is to the side of the surgeon with a monitor at the lower side of the side of the hernia. The optical port is placed umbilically and the operating ports are placed in the mid-clavicular line above and below the umbilicus. Here we start the operation with observing the abdominal cavity and you can see here an inguinal hernia. The anatomy is as such, we will take our incision from the lateral to the medial aspect, starting on the level of the superior aspect of the iliac spine. We mark it with the coagulation both medially and laterally, and then we connect the 2 marks that are previously placed with coagulation. The medial aspect is at the umbilical ligament, as seen here. This serves both in helping the surgeon continuing the correct line of dissection, and to open the peritoneum. As you can see here, careful sharp and electrocautery dissection is used. We start on the lateral aspect and we go medially. Once medially, we head somewhat cephalad to make an S-shaped incision. The spermatic fascia remains inferior to this and we continue our dissection in the preperitoneal space, dissecting the peritoneum only and leaving behind the tissues in the preperitoneal space. This is an especially important aspect of the dissection as the surgeon should not violate the peritoneum itself. We continue dissecting the peritoneum until we reach the spermatic fascia. The dissection then continues inferiorly towards the pubic bone and medially towards the midline. The left hand of the surgeon is used to retract the peritoneum inferiorly away from the preperitoneal space. Here we continue inferiorly until we reach the pubic area with the prevesical area. As you can see, the hernia with the spermatic fascia remains in this midline area now we are working towards that area with our dissection. As we approach the pubis bone seen here, it must be important to remember that 60% of the patients may have a corona mortis in this area. This is the vein between the epigastric and obturator veins and can cause significant bleeding if damaged. Once medially and laterally the peritoneum has been dissected, we now turn to the spermatic fascia itself with the hernia sac. We start on the medial aspect to parietalize the spermatic fascia and to dissect out the hernia sac itself. This dissection is continued carefully, again using sharp dissection to dissect free the spermatic cord structures from the hernia sac. Here we can see the spermatic cord well visualized. We continue to dissect the hernia sac free as we parietalize this area. We can see now that we retract the peritoneum and the hernia sac away from the spermatic cord and fascia structures. The hernia sac itself is being dissected away from the area. If a lipoma is present as it is in this case, we choose to remove the lipoma. This is to avoid any confusion from the patient or practitioner as to a recurrence of the hernia itself. Once the lipoma is completely dissected, it is removed from the abdominal cavity. Here we can clearly see the anatomy of the dissected area with a parietalization of the hernia. We have the inferior epigastric vessels, the hernia site and below the pubic area. Now we will fix the mesh into place, we use a non-absorbable mesh and fix it in place using a stapling device. The areas to avoid are the epigastric vessels and lower 2 triangles of the area of the spermatic cord itself and laterally where the nerves are placed and can cause neuralgic pain. The mesh is introduced through a 12mm port and unrolled in this case medially to laterally. We use an uncut mesh and place it over the spermatic cord and fascia itself. One of several methods can be used to put the mesh in place. Here we chose to use a stapling device to fix the mesh to the abdominal wall. You must be careful to avoid the epigastric vessels as seen here while doing the fixation of the mesh to the abdominal wall. The mesh will also now be placed on the Cooper’s ligament at the pubic site and the pectineal ligament, and also fixated medially. The mesh is not fixated medially to avoid damaging vessels and nerves. Very important is the closure of the peritoneum itself. We use an overlapping technique as you see here, overlapping the peritoneum to itself and placing fixation staples in this case. The medial aspect of closure of the peritoneum is especially important to avoid any herniation of abdominal cavities to this area. We overlie the umbilical ligament to this area for extra security. This concludes our trans-abdominal preperitoneal hernia repair.