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TAPP (transabdominal preperitoneal) repair of a right infraumbilical Spiegelian hernia

Authors

Abstract

This video demonstrates how the principles of TAPP procedures may be applied to repair Spiegelian hernia of the abdominal wall.

Catégorie

routine cases

Mots-clés

TAPP, transabdominal preperitoneal repair, right infraumbilical Spiegelian hernia, laparoscopy

Type de vidéo

Durée

08'10''

Publication

2008-07

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Jul 2008;8(07).
URL: http://www.websurg.com/doi-vd01en2392.htm

TAPP (transabdominal preperitoneal) repair of a right infraumbilical Spiegelian hernia

1. Patient and trocar position 00'30''

The patient is supine. We normally use 3 ports for incisional or other parietal hernia. Two 10mm and one 5mm ports are used.

2. Case commencement 00'40''

A second 10mm port gives us leverage to use clips for bleeders, change the location of the 10mm camera and to put the mesh under direct vision.

3. Clarification of hernia anatomy 00'51''

In this case, a general laparoscopy through the umbilical port site reveals the presence of a Spiegelian hernia in the right pararectus area as evident by outside pressure in the right iliac fossa. I always mark the hernial site on the skin surface with permanent marker and comparison with the anatomy in the inside is very helpful to find your way around during the dissection. The peritoneum is very resilient in the suprapubic area; therefore, it tends to stretch in front of the trocar. One should be wary of this situation as bowel damage can occur if the pneumoperitoneum is not fully established. As you can see that the defect is small, therefore we only need to mobilise enough peritoneum to put in 10 by 12cm mesh. Here we are testing the laxity and resilience of the peritoneum to ascertain the operative difficulty in dissecting it off the abdominal musculature.

4. Peritoneal dissection and development of preperitoneal space 02'02''

We use unipolar diathermy scissors for this type of dissection. We try and keep close to the peritoneum but in this area I usually find that the preperitoneal fat is intimately related and doesn’t come off the peritoneum as it does in the inguinal region. As a result, the chances of bleeding are slightly increased. We should be careful in dissecting as the inferior epigastric vessels are in the close proximity and some bleeding is very likely. We use a combination of blunt and sharp dissection with the judicial use of diathermy. TAPP repair is not essential for this hernia. One could simply use a newer bilayer intraperitoneal type of mesh to decrease the chances of adhesion formation. Although those meshes are costly, having used these meshes for more than a year, I am not totally convinced that they are perfect therefore wherever possible I try and avoid them by using the mesh on the outside of the peritoneum. An arterial spurter, which you just saw, from the edge of the peritoneum required some diathermy coagulation following that we continue with a combination of blunt and sharp dissection. The dissection close to the hernial defect is slightly more difficult as the tissue is bulkier, which requires to be dissected with care. We are lucky that there is no bowel in the hernial sac, which may compound the difficulties. You can very clearly see the hernia defect, which is marked and previously shown in relationship with the inferior epigastric vein (IEV) and the border of the rectus muscle. We only need to dissect about 4cms away from the margins of the defect in order to put an appropriate size mesh. Although the dissection may look slightly wet and coloured, nevertheless the anatomy is clear. The hernia defect is in the centre and the markings show the inferior epigastric vessels and the lateral border of the rectus muscle. There might be some difficulty in putting the mesh in because of the IEV coursing through the middle of the operative field. We reckon a little bit more dissection is required on the medial aspect to do a reasonably sound hernia repair. Slight bleeding encountered during the dissection of the IEV can be easily managed by either diathermy coagulation or by the use of clips. We decided to clip and divide the IEV as they might compromise the repair although it is not essential. Last bit of posterior dissection is to make sure a well fitting mesh without any rolled edges. We can recapitulate the anatomy at this stage, hernia defect is in the centre and top of the field, the rectus border is forming the medial boundary of the defect, the IEV has been divided.

5. Mesh placement 06'25''

And all around there seems to be an ample space to insert a 10 by 12cm Prolene mesh. The Prolene mesh is rolled lengthwise and inserted through the working 10mm port. I agree that it is slightly more difficult to unroll a Prolene mesh compared to some newer alternative but it is very cost-effective. I think it requires only 3-4 tacks superiorly to keep the mesh in place. Posterior tacks should be avoided because of the proximity of cord structures and iliac vessels. I avoid a large number of tacks because tack site pain is quite common. After tacking the mesh as final step, we close the divided peritoneum as flat as possible by using the same tacker, some surgeons like to stitch and claim better results in terms of postoperative obstruction and strangulation. I probably agree but find it easier and less time-consuming to do it this way. Adhesions are inevitable whichever method is used.

6. Re-approximation of peritoneum 07'42''

As a safeguard, I try to make sure that the hemostasis is perfect, the exposed bowel is covered with the omentum so that it is not in the immediate proximity of the staples or stitches. Finally, I do a controlled pneumodeflation to try and minimize any bowel adhesions. There are a number of advantages of using this approach. These are minimal tissue trauma especially to the muscles due to cutting and stretching, the ability to use a tried and tested mesh, which is cheaper than newer bilayer meshes and the possibility of formation of least amount of adhesions.

7. Procedure end 08'23''

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