Nyhus IIIb left indirect inguinal hernia repair in a young male patient: laparoscopic transabdominal preperitoneal approach (TAPP)

This didactic video is a detailed demonstration of the TAPP approach for inguinal hernia repair. It is suitable for all general surgeons. An excellent description of the anatomy of the inguinal region from the intra-abdominal laparoscopic view is presented.

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Nyhus IIIb left indirect inguinal hernia repair in a young male patient: laparoscopic transabdominal preperitoneal approach (TAPP)

Authors

Abstract

This didactic video is a detailed demonstration of the TAPP approach for inguinal hernia repair. It is suitable for all general surgeons. An excellent description of the anatomy of the inguinal region from the intra-abdominal laparoscopic view is presented.

Mots-clés

TAPP, left indirect inguinal hernia repair, laparoscopy

Type de vidéo

Vidéo chirurgicale

Durée

19'30''

Publication

2007-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2007;7(05).
URL: http://www.websurg.com/doi-vd01en2109.htm

Nyhus IIIb left indirect inguinal hernia repair in a young male patient: laparoscopic transabdominal preperitoneal approach (TAPP)

1. Trocar placement 00'14''

I will show you inguinal hernia repair using the TAPP approach (totally abdominal preperitoneal laparoscopic approach for left inguinal hernia repair). Now to the set-up of the patient. The surgeon stands on the opposite side of the hernia. There is one assistant, a nurse (the presence of a nurse is not always necessary since 2 people are enough for this surgery). The patient is placed supine, arms opposite to the hernia alongside the body for easier, atraumatic manipulation during the procedure. I will use 3 trocars, one optical and 2 working ports. The landmarks that you see on the abdomen are: the pubis, left and right anterior superior iliac spine, the rib, and the vertical midline, right and left mid-clavicular line, left and right anterior axillary line, horizontal line through the umbilicus at a minimum 20cm distance to where we will introduce the 1st trocar (that is the optical trocar). We introduce it using a mini-open technique for the optical trocar. For laparoscopic control, I have introduced 2 lateral trocars, B and C. After insufflation of the abdominal cavity, we use the zero degree scope.

2. Laparoscopic exploration 02'15''

We do a panoramic exploration and then we can pinpoint a few anatomical landmarks. Here is an overview of the left pelvic anatomy. There is a defect here that I will describe later. We have a vertical anatomical structure converging to the umbilicus. This is the umbilical artery or ligament, right and left, the urinary bladder anteriorly, the urachus is at the summit of the urinary bladder. On the right side, you have another vertical structure, the epigastric artery with 2 other structures lateral and medial to it, that are venous. Other structures more posteriorly and laterally, visible on the right are the spermatic vessels, the vas deferens duct that crosses the umbilical artery, and we will do the dissection of the space towards this area. Lateral to the epigastric vessels and above a line that is between the anterior superior iliac spine and the pubis, where we have the inguinal ligament, we have an area lateral to the epigastric vessels, we have the external inguinal area between the epigastric vessels and the umbilical artery, we have the mid-inguinal area where we will find the direct hernia and femoral hernia, and medial to the umbilical ligament and lateral to the urachus, we will have the internal inguinal area where we will find the internal direct or indirect inguinal hernia. As you can see, the hole is the internal inguinal ring, normal in this case where the spermatic vessels and the vas deferens converge. This is the cord, the origin of the cord and of the inguinal canal where we will have the indirect inguinal hernia. You see the spermatic vessels with medial retraction, the vas deferens with medial retraction, progressively we have the internal part of the internal inguinal ring that retract medially because of the hernia. Epigastric vessels are not perfectly visible. They are here. All the structures are retracted medially. You can see a large defect here similar to a direct hernia. It is a type 3b hernia according to Nyhus classification. It’s not a type 2 because we have a view on the inguinal canal and on the external inguinal ring using a zero degree scope introduced in the umbilicus. Now my landmarks for doing this type of surgery. You can see my finger pushing medial to the anterior superior iliac spine.

3. Peritoneal incision 06'45''

I will do a mark to show you (it’s not necessary to do it) and I will do a horizontal incision. In the beginning, I’ll do an incision close to the defect. It’s not a good idea. I have to do a large and higher incision like this; if I have no experience to be sure that will not modify the horizontal incision, I push on the abdomen on the horizontal line through the anterior superior iliac spine. I’m doing an incision of the peritoneum and I will complete only the peritoneum, not too deep. It’s easier in obese patients. Due to my traction with my left hand, you see that posteriorly I open the space with gas and I have my target. I’ll do my incision towards this landmark I have determined at the beginning. This is a horizontal line. Don’t hesitate to go laterally. I begin my opening. My left hand is the most essential tool for the dissection of this space. I’m pulling posteriorly opening the space using traction and counter-traction. The same maneuver is done laterally. I don’t dissect immediately the hernia sac. Like 2 fingers doing the dissection, I can move on rapidly. To avoid the curtain effect, you see that I have done a vertical incision. If I don’t do it, I will have the peritoneum doing this and I will not have the same view, we will have a curtain effect that will hide part of the operative field, and it is more important when it is a lower incision. Because I have then to dissect the superior flap to position the mesh very well and I will have more flap. I’m beginning the freeing of the hernia sac. I can use lateral dissection on the spermatic vessels, I’m pulling on the peritoneum staying close to it. It’s easier when it’s a direct hernia because the sac comes more easily. We continue the dissection. We have seen the vas deferens. I’m freeing the peritoneum from the spermatic vessels. I’m dissecting staying not far from the vas deferens that you see here. I’m freeing largely to do a parietalization. We put the cord on the posterior wall of the abdomen. I’m freeing the crossing between the vas deferens and the umbilical ligament as you can see very well here. Dissection continues until reaching this area. Why? Because when I will put the mesh, it will cover the space more easily, particularly posteriorly to the iliopubic branch. Now see Cooper’s ligament, the iliopubic branch, this is the corona mortis, anastomosis between epigastric or iliac femoral and umbilical vessels. We have the foramen obturator just behind and the obturator vessels and nerve running behind. I have finished the dissection. Perhaps I can dissect more behind close to the spermatic vessels.

4. Inguinal anatomy 13'15''

We have a triangle done by the spermatic vessels laterally and vas deferens. This is the triangle of Doom. Why such a name? Because we have big iliac and femoral vessels, we see that very well on this side. It is dangerous to dissect too close from the vessels and also to put staples, and to coagulate too much in this area. Lateral to the spermatic vessels and the inguinal ligament that we don’t see but we know it’s a ligament between the anterior superior iliac spine and the pubic bone. We can see both if we dissect more. It’s not good to see too much, it’s because we have dissected too deeply and the risk of pain may be higher. We have a lot of nerves running behind. This is the triangle of pain. Don’t put staples in this area and don’t fix a mesh in this area, don’t coagulate too much and too deeply because the risk is to have injury of nerves and postoperative pain. Sometimes if we have not incised enough high, we have to complete the dissection like this pulling to position the mesh well. Remember I incise on the horizontal line through the anterior superior iliac spine. We will put a non-absorbable polypropylene mesh.

5. Mesh placement 14'55''

Here is the mesh. Just imagine this is the left side of the patient, this is the right side. For the left side, I will put the mesh like this. This is the medial part, this is the superior part, and lateral part of the mesh. The spermatic vessels and iliac vessel will be just like this like my 2 fingers. I roll the mesh from lateral to medial, and from anterior to posterior. I think that using a composite mesh, made of polyester is good too. I have rolled the mesh and I introduce it through the 12mm trocar and push it in the preperitoneal space. We reintroduce the scope, and as you see the mesh is well positioned. I’m maintaining the medial part of the mesh and I unroll the mesh. The size of the mesh is 12cm medially and 15cm, if I use a bilateral mesh, and 27cm wide. I have to fix the mesh on Cooper’s ligament. Now it is fixed. I go towards the anterior superior iliac spine, and I fix it like this.

6. Peritoneal closure 17'30''

It is not necessary to fix more. I will close now. I have not fixed 20 cases and I have had 2 early recurrences. Therefore I will always do fixation. The mesh can move postoperatively. When you have a small hernia, it’s not really important, but when you have a large hernia, there is a risk of moving. We can complete the closure using an overlapping of the inferior flap and covering the superior one. It’s also why it’s important to fix because you remember that the mesh is fixed with the inguinal ligament, medial and lateral fixation. This is the axis where the mesh will not move. It is particularly important to cover anteriorly.