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Transabdominal preperitoneal approach (TAPP)

Authors

Abstract

The description of the transabdominal preperitoneal approach (TAPP) covers all aspects of the surgical procedure used for the management of inguinal hernia.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: hernia types, Nyhus classification, laparoscopic classification, exposure and exploration, incision of peritoneum, preperitoneal dissection, hernia sac dissection, preperitoneal space, the mesh, mesh placement, fixing the mesh, closing the peritoneum.
Consequently, this operating technique is well standardized for the management of this condition.

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2001-03

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E-publication

WeBSurg.com, Mar 2001;1(03).
URL: http://www.websurg.com/doi-ot02en194.htm

Transabdominal preperitoneal approach (TAPP)

1. Introduction

Inguinal hernias are a common pathology. Each year, more than 2,000,000 hernia repair operations are performed worldwide (95% of cases observed in men).
The use of a non-absorbable mesh placed in the preperitoneal space for the treatment of inguinal hernias was first described by Rives in 1966 (Rives et Nicaise, 1966). In 1975, Stoppa introduced the use of a large mesh prosthesis via a posterior approach to the inguinal region for the repair of bilateral hernias (Stoppa et al., 1975). This prosthesis was meant to reinforce the posterior aspect of the weakened transversalis fascia.
Stoppa’s procedure was our reference procedure before the advent of laparoscopic surgery (close to 1,000 such procedures performed). Since 1990, we have been performing the transabdominal preperitoneal approach (TAPP) which has enabled us to apply Stoppa’s principles using the laparoscopic approach. Stoppa’s principles include:
- a wide dissection of the preperitoneal space and the myopectineal region;
- dissection of the hernia sac with parietalization of the spermatic cord;
- placement of a wide non-absorbable polypropylene mesh prosthesis.
Because of our highly successful results, we continue to use this approach despite a current trend towards a totally extraperitoneal approach (TEP).

2. Anatomy

• TAPP approach

A transabdominal approach to the preperitoneal space had never been described before laparoscopy.
This approach permits the identification of anatomical structures prior to dissection in order to facilitate the dissection.

• Region delimitation

The various anatomical structures delimit external, medial and internal inguinal regions.
1. Urachus
2. Umbilical artery
3. Epigastric vessels
4. Inguinal ligament
5. Ductus deferens
6. Spermatic vessels

• Posterior view/abdomen

• External inguinal region

External inguinal region: where indirect hernias are localized
1. External inguinal region

• Medial inguinal region

Medial inguinal region: where direct and femoral hernias are localized
1. Medial inguinal region

• Internal inguinal region

Internal inguinal region: where direct and internal oblique hernias are localized
1. Internal inguinal region

• Danger areas

1. The Triangle of Pain: Potential for nerve injury or entrapment.
2. The Triangle of Doom: Potential injury to the large vessels.

• Laparoscopic view

1. Urinary bladder
2. Pubis
3. Umbilical artery
4. Ductus deferens
5. Internal inguinal ring
6. Spermatic vessels
7. Triangle of Pain
8. Triangle of Doom
9. Omentum

• Posterior preperitoneal view

• Anatomical structures

1. Urinary bladder
2. Corona mortis vein
3. Spermatic sheath
4. External extension of the urogenital fascia
5. Genital branch of the genitofemoral nerve
6. Femoral cutaneous nerve
7. Inguinal ligament
8. Transversalis fascia
9. Peritoneum

• Laparoscopic view

1. Urinary bladder
2. Pectineal (or Cooper’s) ligament
3. Epigastric vessels
4. Corona mortis vein
5. Urogenital fascia
6. External extension of the urogenital fascia

3. Hernia types

• Hernia types

The risk of recurrence varies according to the anatomical type of hernia. Hernias are classified depending on their location in the inguinal region.

• Types

• Indirect hernias

External oblique indirect hernias are located external to the epigastric vessels. They are situated along the path of the inguinal canal running from the deep inguinal ring towards the homolateral scrotum which they may reach in cases of voluminous hernias.

• Direct hernias

Direct hernias are situated above the inguinal ligament medial to the epigastric vessels. They represent a weakness of the posterior wall of the inguinal canal.

• Femoral hernias

Femoral hernias are situated below the inguinal ligament usually medial to the femoral vessels. They are often small in size.

• Multiple hernias

Multiple hernias combine direct and indirect hernias and appear as a pantaloon presentation (overlapping the epigastric vessels).

• Bilateral hernias

Bilateral hernias are common (15% of cases) especially with direct hernias (up to 30% of cases) either of synchronous or metachronous presentation justifying systematic bilateral hernia repair for some authors.

4. Nyhus classification

• Nyhus classification

The Nyhus classification is needed to compare the various types of hernias in order to properly evaluate the results of various therapeutic modalities (Nyhus, 1989). Other classifications exist. Classification systems can be complex but must remain easy to use. Indeed, certain classifications (Cristinzio and Corcione, 1992) propose an extensive, yet poorly manageable classification.
1. External ring
2. Inguinal canal
3. Internal ring

• Type I

Indirect inguinal hernia with a normal internal ring
1. Internal ring

• Type II

Indirect inguinal hernia with a dilated internal inguinal ring with the posterior inguinal wall intact. It often occurs in the young adult.
1. Inguinal canal

• Type III

- Direct hernia (IIIa): The posterior wall of the inguinal canal, protected by the transversalis fascia posteriorly, is damaged. The risk of recurrence is high as this type of hernia often represents a weakening of the muscular wall.
- Indirect hernia (IIIb): The deep inguinal ring is dilated, usually on its medial part, exerting pressure on the epigastric vessels as the posterior wall of the inguinal canal is absent. The risk of recurrence is great.
- Femoral hernia (IIIc): It develops below the inguinal ligament. It can be located either medial to the femoral vessels (regular position), or anterior. It can also be within the femoral sheath or outside it.
1. IIIa: Damaged posterior wall
2. IIIb: Dilated internal ring
3. IIIc

• Type IV

Recurrent hernia

5. Laparoscopic classification

• Laparoscopic classification

This classification is closely related to Nyhus’s, yet it differs from Nyhus’s in that the view is no longer anterior but posterior with all the anatomical aspects described according to this approach.
1. External inguinal region
2. Medial inguinal region
3. Internal inguinal region

• Type I

1. Congenital hernias with a narrow internal ring
They may be associated with a patent processus vaginalis.

• Type II

1. External oblique inguinal hernias with a dilated internal ring
It is impossible to visualize the external ring with a 0° endoscope introduced in the umbilical region. The posterior wall of the inguinal canal is well preserved.

• Type III

• Generality

The posterior wall of the inguinal canal is damaged.

• IIIa

Direct hernias situated above the inguinal ligament between the epigastric vessels and the umbilical ligament.
1. Umbilical ligament
2. Epigastric vessels
3. Inguinal ligament
4. Direct hernia

• IIIb

External oblique hernias with a dilated internal ring. Seen via laparoscopy, they are different from type II hernias because the external ring of the inguinal canal becomes apparent through the internal ring with the 0° endoscope introduced in the umbilical region. The length of the canal is reduced. The posterior wall of the inguinal canal is almost absent.
1. Medially-displaced epigastric vessels
2. Hernia with a dilated internal ring
3. External ring

• IIIc

Femoral hernias identified in the medial inguinal region below the inguinal ligament.
1. Medial inguinal ring
2. Femoral hernia
3. Inguinal ligament

• Type IV

Recurrent hernias:
Hernias treated after placement of a mesh prosthesis in the preperitoneal space must be differentiated from those treated with other techniques, as mesh placement in the preperitoneal space may result in major fibrosis, leading to operative difficulties.
1. Scarred zone
2. Mesh placed in the preperitoneal space

6. Indications

• Indications

The TAPP procedure can be considered for all adult patients, regardless of the type of hernia. The best indications are as follows:
- type III hernias;
- bilateral hernias;
- type IV hernias;
- obesity, hard labor, and strenuous physical activities (heavy lifting and sports).
1. IIIa: Damaged posterior wall
2. IIIb: Dilated internal ring
3. IIIc
4. IV

• Borderline indications

- type I or II hernias except when associated with another type of hernia or in cases of bilateral hernias;
- voluminous sliding hernias;
- strangulated hernias, diagnosed early.
1. I: Normal internal ring
2. II: Dilated internal ring

• Contraindications

There are very few contraindications:
- contraindication to general anesthesia;
- extensive intra-abdominal adhesions;
- extremely voluminous sliding hernias with the bowel attached to the hernia sac;
- late diagnosis of strangulated hernias with advanced bowel obstruction.
1. Voluminous sliding hernia

7. Operating room set-up

• Basics

The operating room should be large enough to accommodate all of the anesthetic and surgical equipment.
The patient should be positioned depending on the localization of the hernia, on whether it is one-sided or bilateral, and on the positions of the team and the equipment.
1. Example for a right-sided hernia

• Patient

General anesthesia is required. Certain teams perform this procedure using epidural anesthesia.
The patient is in the supine position.
A slight 5° to 10° Trendelenburg tilt is often necessary especially when the patient is obese or presents with a voluminous hernia.
The patient’s arm on the side of the hernia is placed at a right angle and the other arm is tucked alongside the body.
A urinary catheter is not used, but voiding takes place just before the procedure.
A gastric tube is used to decompress the stomach (to be removed at the end of the procedure).

• Team

The presence of both a surgeon and an assistant is usually needed. The surgeon stands on the side opposite the hernia, close to the patient’s shoulder.
The assistant stands opposite the surgeon.
(The assistant may be replaced by a robotic arm.)
1. Surgeon
2. Assistant
3. Scrub nurse
4. Anesthesiologist

• Equipment

It is preferable to use a 3CCD camera and a cold light source cable which is long enough to ideally position the video unit.
The monitor is generally placed on the side of the hernia or at the foot of the table.
1. Anesthetic equipment
2. Operating table
3. Instrument table
4. Electrocautery
5. Video unit

• Variation

• Bilaterality of lesions

The bilaterality of lesions is unsuspected in 15% of cases. For most authors, the positioning of the patient will be similar to the one required for operation of a bilateral hernia.

• Left hernias

The patient is in the supine position.
A slight 5° to 10° Trendelenburg tilt is often necessary.
The patient’s arm on the side of the hernia is placed at a right angle whereas the arm opposite is tucked alongside the body.
The surgeon stands on the side opposite the hernia, close to the patient’s shoulder. The assistant stands opposite the surgeon.
1. Surgeon
2. Assistant
3. Scrub nurse
4. Anesthesiologist

• Bilateral hernias

The patient is in the supine position.
A slight 5° to 10° Trendelenburg tilt is often necessary.
Both arms should be tucked alongside the body.
In bilateral hernias, the surgeon and the assistant change sides during the procedure.
The monitor is usually placed at the foot of the table.
1. Surgeon
2. Assistant
3. Scrub nurse
4. Anesthesiologist

8. Trocar placement

• Principles

Three trocars are used: a 10/12 mm optical trocar and two 5 mm operating trocars. The current trend is to decrease the trocar size as the use of smaller trocars reduces pain and the risk of eventration.
Trocars must be placed high enough on the abdominal wall to make the procedure easier to perform.
1. Right midclavicular line
2. Left midclavicular line
3. Horizontal line to the umbilicus

• Optical

The 10/12 mm optical trocar is placed in the supraumbilical position. It is the first trocar to be inserted after puncture with a Veress needle or by open laparoscopy. The mesh will be introduced through this trocar at the end of the dissection.

• Operating

The first 5 mm (occasionally 10 mm when necessary) operating trocar is situated on the side of the hernia on the midclavicular line 1 to 2 cm above the horizontal line at umbilical level.
The second 5 mm operating trocar situated the side opposite the hernia is placed on the midclavicular line 1 to 2 cm below the horizontal line to the umbilicus.
The operating trocars are obliquely introduced into the wall and directed towards the hernia, taking care to avoid the epigastric vessels.

• Variation

• Left-sided hernias

The 10/12 mm optical trocar is placed in supraumbilical position. It is the first trocar to be introduced after puncture with a Veress needle or by open laparoscopy. The mesh will be introduced through this trocar at the end of the dissection.
The first 5mm (occasionally 10 mm when necessary) operating trocar is situated on the side of the hernia on the midclavicular line 1 to 2 cm above the horizontal line to the umbilicus.
The second 5 mm operating trocar situated on the side opposite the hernia is placed on the midclavicular line 1 to 2 cm below the horizontal line to the umbilicus.
The operating trocars are introduced at an angle into the wall and directed towards the hernia, taking care not to damage the epigastric vessels.

• Bilateral hernias

The operating trocars are situated on the midclavicular lines at umbilical level.

9. Instruments

• Basics

The procedure can be performed using standard instrumentation. In this case, intracorporeal sutures are applied. This considerably reduces the cost of this type of procedure.

• Optical

- 0° laparoscope: as a rule, the optical device has a 0° visual axis and a 70° visual field with an excellent depth of field (5 to 10 cm) avoiding constant focusing;
Certain authors use an optical device with a 30° visual axis (sometimes very useful in obese patients).
The cold light source cable must be long (>= 3 metres);
A 3CCD camera is preferable, notably in cases of voluminous hernias or when the patient is obese.
A powerful light source (at least 250 Watts), if possible a Xenon light source, is necessary to perform the procedure safely.
1. 0° laparoscope

• Operating

1. Monopolar scissors
2. Atraumatic fenestrated graspers (X 2)
3. Scissors with wire
4. 10/11 mm angulated or straight clip applier
5. Needle holder
6. 5 mm stapler

• Other instruments

1. Suction-irrigation device (when necessary)
2. Bipolar grasper (when necessary)

10. Exposure and exploration

• Exploration

After inserting the optical trocar, the abdominal cavity is explored. The unilateral or bilateral character of the hernia is verified (an unsuspected additional hernia is found in 10% of cases).
Exposure also assesses the hernia pathology before starting the dissection and allows the surgeon to search for associated conditions which may contraindicate a laparoscopic procedure.

• Simple hernias

• Classification

These are isolated hernias which are perfectly defined anatomically. We distinguish:
1. Indirect hernias;
2. Direct hernias;
3. Femoral hernias.

• Direct hernias

Direct hernias (Nyhus type IIIa) are situated medial to the epigastric vessels, external to the umbilical ligament and above the inguinal ligament. They may course medially and slide towards the posterior surface of the inguinal canal to reach the rectus muscle anteriorly.
1. Epigastric vessels
2. Inguinal ligament

• Indirect hernias

Indirect hernias are situated external to the epigastric vessels. They may be type I, II or IIIb hernias (photo) according to the Nyhus classification.
1. Umbilical ligament
2. Internal ring
3. External ring

• Femoral hernias

Femoral hernias (Nyhus type IIIc) are situated in the medial inguinal region below the inguinal ligament. They are often small in size.
1. Inguinal ligament

• Sliding hernias

Sliding hernias are often indirect hernias. They are composed of a voluminous hernia sac and a sliding part of a hollow viscus (or of the urinary bladder). The contents of the sac may be difficult to reduce, especially when they are adherent to the hernia sac, notably in left-sided hernias.
1. Left-sided sliding hernia

• Recurrent hernias

• Cases

The problem is different depending on whether the hernia occurs after an anterior approach or after a posterior approach with mesh placement in the preperitoneal space.

• After anterior approach

The preperitoneal space is intact whether or not the patient has had a mesh placed anteriorly. These hernias are often situated in the internal inguinal region. The presence of peritoneal scarred folds sometimes obstructs the correct visualization of these hernias.
1. Scarred zone

• After mesh placement

After mesh placement in the preperitoneal space:
Whether the mesh is placed using a posterior or an anterior approach, it is always associated with major preperitoneal fibrosis. The recurrence is due either to a mesh that was too small, or to the sliding or the plication of the mesh.
1. Inguinal ring

• Hernia content

Before the procedure is started, the contents of the hernia sac are reduced and examined (small intestine, colon, bladder).
In chronic types of hernias, the intestine may present after-effects of incarceration.
In cases of sliding hernias to the left, the sigmoid colon may have entered the hernia sac, which may hinder the reduction.
In cases of incarcerated and/or voluminous hernias, external pressure associated with atraumatic traction of the viscera is sometimes necessary.

11. Incision of peritoneum

• Incision of peritoneum

Incision of the peritoneum must be large and high enough to open the preperitoneal space in accordance with Stoppa’s principles.
The posterior peritoneal flap naturally drops posteriorly, allowing overall visualization of the preperitoneal space.
In cases of bilateral hernias, the incision is performed to the right and to the left.

• Unilateral hernias

A high, long, horizontal incision is made in the anterior parietal peritoneum from the inner edge of the anterior superior iliac spine (ASIS) to the outer edge of the root of the homolateral umbilical ligament where it is extended vertically upwards to prevent the upper peritoneal flap from dropping (curtain effect).
1. ASIS
2. Root of the umbilical ligament

• Bilateral hernias

In case of bilateral hernias, two incisions are performed. Some authors perform only one horizontal incision from right to left along the line of the anterior superior iliac spine, with division of the umbilical ligaments and of the urachus.

12. Preperitoneal dissection

• Preperitoneal dissection

Dissection starts laterally at the level of the retroinguinal (or Bogros’) space, beginning with parietalization of the spermatic fascia posteriorly and outwards. It is continued medially towards the retropubic (or Retzius’) space, extending behind the symphysis pubis and the iliopubic branch, uncovering the pectineal ligament. The hernia sac is then dissected by continuing the parietalization of the spermatic fascia.
1. Retroinguinal space
2. Spermatic fascia
3. Retropubic space

• Lateral dissection

Dissection is performed close to the peritoneum. The plane of the spermatic fascia described by Stoppa is searched for and progressively parietalized, laterally to medially. The spermatic vessels are visualized fairly high up, at a distance from the internal inguinal ring and from the hernia sac.
1. Spermatic fascia

• Medial dissection

Dissection is once again performed close to the peritoneum whose posterior traction induces pneumodissection of the prevesical space. Dissection is then continued caudally along the prevesical fascia towards the retropubic space and posterior to the symphysis pubis and the iliopubic branch, uncovering the pectineal ligament. Particular care should be taken to avoid the large venous anastomosis between the epigastric vein and the obturator vein (corona mortis), which can be present in up to 60% of cases.
1. Symphysis pubis
2. Iliopubic branch
3. Corona mortis vein

13. Hernia sac dissection

• Hernia sac dissection

Dissection of the hernia sac is a delicate step. It is not always necessary to retract the entire sac, especially in cases of voluminous hernias.
In men, freeing of the sac enables the parietalization of the spermatic cord surrounded by its fascia, in accordance with Stoppa’s technical principles.
In women, the round ligament may be divided in the preperitoneal region to facilitate the dissection of the preperitoneal space.

• Simple hernias

Reduction of the sac is generally easy, whether the hernia belongs to Nyhus type II or to Nyhus type III. The peritoneal lining of the hernia sac is retracted posteriorly and cephalad from the transversalis fascia which itself is pushed anteriorly. Dissection is facilitated by the cephalad retraction of the hernia sac. The sac is freed laterally from the transversalis fascia, in close contact with the peritoneum, by pulling back the spermatic vessels covered by the genital fascia. Then the procedure continues medially by pulling back the ductus deferens covered by its fascia.

• Voluminous hernias

In Nyhus type IIIa or IIIb voluminous hernias, reduction of the sac may be difficult as the sac may be attached to the scrotum (inguino-scrotal hernias). It is not mandatory to resect the entire sac even though there is a risk (<10%) of a postoperative hydrocele which is less serious than a traumatic dissection of the cord.
Depending on the author, either routinely or in case of difficulties, the sac will be incised at the level of the hernial neck, making it easier to free the abdominal portion of the spermatic cord from the peritoneum. The sac may be resected at its base once it has been freed from the proximal peritoneum.
1. Epigastric vessels
2. Incision at the level of the hernia neck

• Recurrent hernias

• Cases

The case is different depending on whether or not the patient has a mesh in the preperitoneal space, on whether the mesh was applied using an anterior or a posterior approach, and whether or not the repair was performed laparoscopically.
1. Scarred zone
2. Mesh placed in the preperitoneal space

• Without mesh

Without preperitoneal mesh:
The peritoneum, which is scarred and fragile, is often torn during the dissection of the preperitoneal space. This must be avoided to prevent the loss of massive peritoneal fluids which may prevent closure of the peritoneum.
1. Scarred zone
2. Hidden defect

• After mesh

After preperitoneal mesh:
It is not mandatory to remove the whole mesh if it is well positioned and well tolerated. A complementary mesh will simply be placed over the extended zone of the defect and the peritoneal incision will be limited to the herniated zone.

• Other types of hernias

• Rare occurrences

Seldom encountered, they are also a good indication for laparoscopy, except, perhaps, in the case of strangulated hernias whose indication is still debated.

• Multiple hernias

They are also called pantaloon hernias, because they overlap the epigastric vessels. They are associated with an intimate adhesion of the sac to the epigastric vessels which may be injured during the dissection.
Pantaloon hernias can sometimes only be handled after opening the preperitoneal space and dissecting the indirect oblique hernia sac which remains medially attached by a pre-hernial lipoma extending from the direct hernia within the epigastric vessels.
1. Epigastric vessels

• Femoral hernias

The small sac is reduced by a firm traction exerted posteriorly, which is sometimes accompanied by a cephalad traction on the inguinal ligament.
1. Inguinal ligament

• Strangulated hernias

For some authors, they are considered an absolute contraindication to the placement of a non-absorbable mesh. However, laparoscopic treatment may be performed if their diagnosis is rapidly established.
The transabdominal approach permits a thorough examination of the abdominal cavity and of its contents. It also allows for assessment of the viability of the incarcerated intestinal segment. The hernia sac is dissected after reduction of its contents.
1. Hernial defect
2. Small bowel

• Obturator hernias

They occur rarely (less than 1%) and may be revealed by pain (entrapment of the obturator nerve) or by a strangulation.
1. Obturator foramen
2. Obturator hernia
3. Obturator nerves and vessels

14. Preperitoneal space

• Preperitoneal space

• Structure identification

Before positioning the mesh, hemostasis and sufficient peritoneal mobilization must be checked for.
At the end of dissection, the posterior aspect of the posterior inguinal region must be visualized as well as the iliac vessels (1), the pectineal ligament (2) and the posterior surface of the iliopubic tract (3), the posterior aspect of the pubis (4) and the psoas muscle (5) covered by its fatty tissue.
The recommended therapeutic strategy regarding pre-hernial lipomas, voluminous hernia sacs and herniation of the transversalis fascia, varies depending on the size of the defect and on the authors.

• Peritoneal dissection

Peritoneal dissection is performed cephalad up to the line of the anterior superior iliac spines. It is continued posteriorly and laterally up to the iliac wing, largely revealing the genital fascia. Posteriorly and medially, the dissection is pursued up to the confluence of the ductus deferens and the umbilical ligament.
1. Bladder
2. Pectineal ligament
3. Ductus deferens
4. Corona mortis vein
5. Genital fascia
6. External extension of the urogenital fascia

• Pre-hernial lipoma

A voluminous pre-hernia lipoma must either be reduced or resected to avoid postoperative swelling bearing resemblance to a recurrent hernia and causing discomfort to the patient.
1. Ductus deferens
2. Lipoma
3. Pectineal ligament

• Hernia sac

The excess of peritoneum is always useful for closing the peritoneal incision. Therefore, the peritoneum should be preserved from the hernia sac. In case of a very voluminous hernia sac, the excess portion of the sac may be resected once the peritoneum has been closed.
1. Hernia sac

• Transversalis fascia

• Fixation technique

Herniation of the transversalis fascia in direct hernias accounts for the postoperative pseudo-recurrences due to the presence of associated seromas. Inverting the fascia and fixing it to the pectineal ligament or to the posterior aspect of the rectus sheath avoids such complications.
1. Transversalis fascia
2. Pectineal ligament
3. Fixation of fascia to the pectineal ligament

• Pectineal ligament

Fixation to the pectineal ligament:
Inverting the fascia and fixing it to the pectineal ligamentis usually easy to perform laparoscopically. Staples or sutures are applied. Nerve structures situated anteriorly to the transversalis fascia must be avoided, especially if sutures are used.
We recommend this technique.
1. Pectineal ligament
2. Inverted transversalis fascia

• Rectus sheath

Fixation to the rectus sheath:
Inverting the fascia and fixing it to the posterior aspect of the rectus sheath, as suggested by G Wantz in the framework of open surgery, is easy to perform via laparoscopy (Wantz, 1996). Staples or sutures are applied. Nerve structures situated anteriorly to the transversalis fascia must be avoided, especially if sutures are used.
1. Posterior aspect of the rectus sheath
2. Inverted transversalis fascia
3. Pectineal ligament

• Parietalization of the cord

This technique has been suggested by Stoppa. It consists of freeing the cord surrounded by its fascia from the posterior portion of the peritoneum. The cord remains in contact with the iliac vessels which it protects.
In women, the round ligament is rarely detachable from the peritoneum. It is best to divide it in the preperitoneal space.
1. Epigastric vessels
2. Spermatic vessels
3. Ductus deferens
4. Round ligament

15. The mesh

• Generalities

The placement of a large non-absorbable mesh in the preperitoneal space ensures the repair of the parietal defect once the spermatic cord has been parietalized.
The mesh must be large (at least 15 cm wide X 10 cm high), non-absorbable and sturdy. It must also be biocompatible and easy to introduce. Most authors use a polypropylene mesh prosthesis, but there is a current trend for using more flexible meshes.

• Type

• Prostheses

A great variety of prostheses may be used, but most authors use polypropylene prostheses.
At the beginning of our experience, we used woven polypropylene meshes; at present we prefer using lighter non-woven ones.
The prostheses used must amply cover the myopectineal region and the posterior aspect of the pectineal ligament.

• Woven polypropylene

Most authors use a loosely woven mesh prosthesis which allows for visualization of underlying anatomical structures. These meshes are criticized for being too rigid, yet this accounts for their good fold memory, which makes them easier to manipulate.

• Non-woven polypropylene

This type of mesh offers different degrees of thickness (from 50 to 90g/m2). It is flexible, atraumatic, hemostatic and is easy to position.
We use it readily in hernias of small size.

• Size and shape

• Unilateral mesh

The mesh must extensively cover the inguino-femoral region.
1. Unilateral mesh
2. ASIS

• Bilateral mesh

The mesh must extensively cover the inguino-femoral region.
1. Bilateral mesh
2. ASIS

• Unilateral hernias

In case of unilateral hernias, the mesh is at least 15 cm wide X 10 cm high on its lateral side and from 12 to 14 cm high medially.
Its polyhedral shape (less high laterally) makes it easy to place. The rounded superior-internal angle facilitates its placement in the retropubic space.
1. Lateral side
2. Inferior side

• Bilateral hernias

In case of bilateral hernias, the one-piece mesh is at least 27 cm wide X 10 cm high laterally and from 12 to 14 cm high medially.

16. Mesh placement

• Principle

The mesh must largely cover the dissected inguino-femoral zone. The mesh is rolled up to be introduced into the abdominal cavity and positioned in the preperitoneal space.

• Rolling the mesh

• Technique

The procedure depends on whether the mesh is unilateral bilateral. Yet, the technical principle is the same: the mesh is rolled up to be introduced in the abdominal cavity via a trocar and to facilitate its placement in the preperitoneal space.

• Unilateral mesh

Unilateral mesh (15 X 10)
The mesh is rolled up from outside to inside and from front to back. The rolling process can be maintained using either a suture which is not too snug, a specifically designed device to allow for introduction, or a laparoscopic grasper.

• Bilateral mesh

Bilateral mesh (27 X 10)
The mesh is rolled up from bottom to top and from front to back, leaving its upper edge free. It must be maintained rolled up using two suture lines placed to the right and to the left to facilitate its handling.

• Introduction of the mesh

The mesh is introduced through the 12 mm trocar directed toward the operative field. The inferior edge of the mesh is held with a fenestrated grasper. Then the mesh is pushed into the supraumbilical optical trocar aiming at the retropubic region. The endoscope is then reintroduced in the supraumbilical trocar.

• Positioning the mesh

• Unrolling

The mesh is progressively unrolled either from inside out, or from top to bottom, depending on the type of mesh used with or without prior fixation.
1. Bilateral
2. Unilateral

• Unilateral mesh

The inferior edge of the mesh is positioned posteriorly to the pubis in the retropubic space. The mesh is progressively unrolled from inside to outside and is placed over the parietalized spermatic cord.

• Bilateral mesh

The mesh is placed posterior to the abdominal wall in the preperitoneal space. The superior edge of the mesh is positioned on the anterior superior iliac spines without being unrolled. Once the mesh has been fixed to the abdominal wall, it is unrolled from top to bottom, covering the parietalized spermatic cord.

17. Fixing the mesh

• Fixation

We feel that fixation of the mesh must be done in order to prevent recurrences (out of 20 patients, we have had 2 recurrences in our experience).
The mesh is fixed to the pectineal ligament and to the pubis. It is also fixed on its upper edge to the abdominal wall.
The mesh must not be fixed caudally and externally in either the Triangle of Pain or the Triangle of Doom.
1. Fixation to the pectineal ligament and to the pubis
2. Fixation to the upper edge of the mesh
3. Fixation to the internal edge of the mesh

• Means of fixation

Absorbable or non-absorbable, the suture or staples must allow for safe fixation of the mesh for a period of at least 15 days, leaving time for the fibrosis to form and fix the mesh globally.
- sutures (our preferred means of fixation): one or two absorbable stitches are recommended;
- staples (in titanium) applied with a straight or angulated 10 mm grasper;
- tacking staples applied with a 5 mm grasper.

• Pectineal ligament

Fixation to the pectineal ligament:
The corona mortis vein must be avoided.

• Fixation to the wall

The internal edge of the mesh is fixed to the anterior abdominal wall.
The upper edge of the mesh is fixed to the anterior abdominal wall on the line of the anterior superior iliac spines.
The upper edge of the mesh can be fixed by a running absorbable monofilament suture.
1. Epigastric vessels

18. Closing the peritoneum

• Closure

Closure of the peritoneal incision must be perfect and tension-free. If an opening remains, it may result in a bowel obstruction due to the incarceration of a loop or to the presence of adhesions on the mesh (1/1,000).
Closure may be achieved using a side-to-side approximation or by overlapping the peritoneal flaps.
Either staples or sutures are used.

• Means of closure

• Principle

Whether the closure is performed by stapling or suturing, it is necessary to have at least a minimum amount of training to achieve this closure without tearing the peritoneum. Stapling devices make this operative step easier.

• Staples

The use of a 10/11 mm trocar is required. Titanium staples prove very effective. They must enter the peritoneum only. Either straight or angled disposable devices may be used.

• Sutures

Using a simple straight line or a suture line reverting its course, they allow for an airtight and safe suture, especially in difficult cases where the peritoneum is fragile and torn. Simple defects can be closed by suturing or stapling.

• Peritoneal flap

Readjusting the peritoneal flap:
The inferior peritoneal flap is lifted up to cover the original incision, extending beyond its superior edge.
1. Peritoneal incision
2. Inferior peritoneal flap

• Peritoneal closure

It must be airtight to avoid any risk of an intestinal loop incarceration, which may cause an obstruction.

19. Postop period

As soon as the patient awakes after surgery, he/she is allowed to ambulate.
Food intake may be resumed on the same day.
Increasingly, hospital discharge is possible on the same day. Otherwise the patient is discharged on POD1.
Physical activities may be resumed on POD1 and return to employment on POD3.
Strenuous and athletic physical activity is possible on around POD15.

Other aspects of PO management include:
- monitoring of wounds and intestinal function, and voiding;
- deep venous thrombosis prevention.

20. Conclusion

The transabdominal preperitoneal approach (TAPP) is a standardized procedure.
It reproduces Stoppa’s procedure with minimal invasiveness.
Its morbidity rate, which is mostly related to the learning curve, is low and equals that of the totally extraperitoneal approach (TEP). Its reproducibility is excellent, although it seems more difficult than the surgical hernia repair techniques with an anterior approach. It requires perfect knowledge of the anatomy of the posterior inguinal region.

21. Reference

Nyhus LM. The recurrent groin hernia: therapeutic solutions. World J Surg 1989;13:541-4.
Rives J, Nicaise H. A propos des hernies de l'aine et de leurs récidives. Sem Ther 1966;42:526-8.
Stoppa R, Petit J, Henry X. Unsutured Dacron prosthesis in groin hernias. Int Surg 1975;60:411-2.
Wantz GE. Experience with the tension-free hernioplasty for primary inguinal hernias in men. J Am Coll
Surg 1996;183:351-6.

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