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LIVE INTERACTIVE SURGERY: left direct inguinal hernia: laparoscopic TAPP approach

D Mutter, MD, PhD, FACS J Marescaux, MD, FACS, Hon FRCS, Hon FJSES, Hon FASA, Hon APSA
Epublication WebSurg.com, Nov 2017;17(11). URL: http://websurg.com/doi/vd01en5084

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We present the clinical case of a 50-year-old patient managed for a left direct symptomatic reducible inguinal hernia, with a palpable impulse on examination. The patient’s history included a left indirect inguinal hernia repair in his childhood. The procedure begins conventionally with an open laparoscopy with the introduction of a supra-umbilical port. The exploration confirms the presence of a left hernia and rules out the diagnosis of right hernia. Dissection starts with a horizontal peritoneal incision, which allows to progressively parietalize all elements of the cord, making sure to stay in contact with the peritoneum. Dissection of the previously operated hernia dating back to the patient’s childhood is slightly more painstaking and constraining due to the presence of adhesion-related scars. However, the parietalization of the peritoneum is carried on without any particular problem, and considering that it is a direct hernia, the deferent duct is very easily identified and parietalized. Reduction of the direct hernia is performed easily with the reintroduction of the transversalis fascia. Given the small size of the hernia, the fascia will not be exteriorized. After complete lowering, a 15 X 15cm polypropylene mesh (Parietene™) is recut to a 13 X 12cm size with external trimming. The mesh is positioned in order to cover all direct and internal hernial orifices. It is only fixed to Cooper’s ligament, to the anterior superior iliac spine, and to the anterior abdominal wall so as to prevent any early mobilization postoperatively. Reperitonization is then performed with peritoneal fixation using absorbable staples (of the AbsorbaTack™ type). Exsufflation is achieved under visual guidance. The entire procedure is performed as an outpatient surgery. The patient was admitted to our unit just before the intervention. He is discharged a few hours later.