Transabdominal pre-peritoneal (TAPP) repair of Amyand's hernia in a 72-year-old man

This video demonstrates the unusual case of an Amyand's hernia, where the appendix is found in the right inguinal hernia sac. The patient underwent 2 previous open inguinal hernia repairs, making the procedure more challenging. This video is recommended to general surgeons.

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Transabdominal pre-peritoneal (TAPP) repair of Amyand's hernia in a 72-year-old man

Authors

Abstract

This video demonstrates the unusual case of an Amyand's hernia, where the appendix is found in the right inguinal hernia sac. The patient underwent 2 previous open inguinal hernia repairs, making the procedure more challenging. This video is recommended to general surgeons.

Mots-clés

Amyand's hernia, right inguinal hernia sac, hernia repair

Type de vidéo

Vidéo chirurgicale

Durée

07'00''

Publication

2007-10

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Oct 2007;7(10).
URL: http://www.websurg.com/doi-vd01en2202.htm

Transabdominal pre-peritoneal (TAPP) repair of Amyand's hernia in a 72-year-old man

1. Exposure 00'18''

The very first few shows that the appendix has just been retrieved from within the sac. There is obvious proximity of the terminal ileum and caecum lying just at the inguinal orifice. As the appendix is pulled in, it becomes clearer that there are further adhesions holding some fatty tissue on the inside of the sac. Some dissection is performed to remove the fat inside into the peritoneal cavity but soon, it is realized that this is only to cause bleeding and further filling of the peritoneum leading to more difficulties in the dissection later on. Therefore, this step is abandoned.

2. Peritoneal incision 01'41''

The anterior abdominal wall peritoneum is then diathermy tattooed starting from the anterior superior iliac spine horizontally towards the midline. Unipolar diathermy scissors is used to make an incision in the parietal peritoneum joining all the tattooed points. Taking care that the incision in the peritoneum is 4 to 5cm higher than the deep ring to ensure a good mesh fit. Claudius Amyand was born in 1681 and was one of the leading surgeons of his day. He performed the first appendicectomy on 6th December, 1745 at St Georges’ Hospital, London. The patient was an 11-year-old child with an inguinal hernia and a fecal fistula, which was discharging into the groin. At operation, the appendix was found in the hernia sac, and the fistula was traced to a perforation of the appendix by a pin. The case was reported in the philosophical transactions of the Royal Society in 1736. Although he was the first to perform appendicectomy, he never got the recognition he deserved just like Littré who described Meckel’s diverticulum in the hernial sac.

3. Pre-peritoneal dissection 03'02''

Interestingly, some 80 years before the birth of Meckel. Preperitoneal space of Bogros is opened lateral to the epigastric vessels using a diathermy scissors and use of sharp and blunt dissection. Now attention is focused on the parietal peritoneum medial to the inferior epigastric vessels to open the space adequately. The dissection has to be completely gentle as you can see that the peritoneum is very flimsy. Despite best possible care that is gentle use of two-handed dissection, it is quite easy to make further holes in the peritoneum especially when it is so thinned out. Once both medial and lateral spaces are adequately opened, dissection is focused upon the area of the inferior epigastric vessels and the sac where dense adhesions are encountered due to previous operations. Soon we are able to make further extra holes adding to later difficulties. Medially the superior pubic ramus is exposed. As you can appreciate, the anatomy is difficult, hence making the job of the cameraman fairly difficult too. Some of you might wonder at this stage whether an open operation might have been easier, and so did I. The strength of the argument that there had been 2 previous failures of the open repair in the past was too strong to give up the laparoscopic approach. Now we concentrate over the vas and testicular vessels and dissection of the peritoneum from them. You will see clearly that the pulsations of the iliac vessels are lateral to the testicular vessels, clearly suggesting medial transposition of the cord structures during previous repairs. Look at the anatomy of the hernial defects. Once can clearly see an indirect, a direct, and a further medial defect just above the pubic tubercle. Judicious use of diathermy dissection is done to make the anatomy clearer. The triangle of Doom is very well visible. Nevertheless, the iliac vessels are not in its depth as previously explained. They seem to have been shifted laterally. The dissection of the sac reveals again a fair degree of adhesions. The peritoneum at this point is very flimsy. We tease open the tissues a little bit further just behind the margin of the anterior parietal peritoneum.

4. Mesh placement 05'30''

I think we have dissected enough space to put and fix a 10 by 15cm mesh. The mesh is gently folded lengthwise to decrease thickness and put into the optical port past the valve to avoid damaging the inner coating of the mesh. The telescope is used to push it further into the abdominal cavity at the desired location. The mesh is placed free of wrinkles covering all 3 hernia defects and fixed the Cooper’s ligament midline and laterally. I’m sure you might be thinking that how in the world am I going to be able to close this defect after putting the mesh in? Well, exactly my thoughts too. I think at this stage we need to think outside the box and improvise. We decide to use an intra mesh, which is a bi-layer mesh coated on the inside of the polypropylene mesh with a layer of PTFE. This mesh is recommended for intraperitoneal use for the repair of incisional hernias in order to decrease the chances of adhesion formation. This mesh is 5 times costlier, yet I think useful to use in this particular circumstance to give the best chance to the patient to heal in the best possible way, that is to avoid adhesion formation, which no doubt would add to his future morbidity. Although this mesh is going to attract least amount of adhesions, yet I thought that I must try and cover as much of the mesh as possible, especially the edges so that they are not raised, thereby attracting the bowel to come in between the mesh and the abdominal wall. Therefore, we tried our best to cover as much of the mesh with the peritoneum as possible. The task seemed near impossible in the beginning due to flimsy and battered peritoneum. Nevertheless, the peritoneal sac usually comes in handy in these cases to cover the defect. You can clearly appreciate the proximity of the caecum. In the end, only a small area of 1 to 2cm remains uncovered. Controlled deflation of the pneumoperitoneum should help the caecum cover the remaining small hole in the peritoneum, which we hope should soon reperitonealize. You have all noticed that the appendix was held in forceps a couple of times. I was mindful that was only held extremely gently lest it may become the cause for postoperative appendicitis. I was relieved to discover that the patient could go home the day after the surgery without any symptoms or complications.