Laparoscopic TAPP approach for a Nyhus IIIb inguinal hernia in a male patient

Following the laparoscopic revolution, laparoscopic hernia repair has become one of the most common laparoscopic operations. Several studies have demonstrated a definite advantage over open repair with regards to reduced postoperative pain and earlier return to work and normal activities, especially in young patients. When repairing recurrent hernias, the TAPP repair offers an advantage of dissection in a previously non-damaged area. A stepwise approach of the technique with detailed description of the anatomical landmarks is performed.

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Laparoscopic TAPP approach for a Nyhus IIIb inguinal hernia in a male patient

Authors

J Leroy, J Marescaux

Abstract

Following the laparoscopic revolution, laparoscopic hernia repair has become one of the most common laparoscopic operations. Several studies have demonstrated a definite advantage over open repair with regards to reduced postoperative pain and earlier return to work and normal activities, especially in young patients.
When repairing recurrent hernias, the TAPP repair offers an advantage of dissection in a previously non-damaged area.
A stepwise approach of the technique with detailed description of the anatomical landmarks is performed.

Classification

routine cases

Keywords

TAPP approach, inguinal hernia repair

Media type

Surgical video

Duration

12'00''

Publication

2009-01

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E-publication

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2516.htm

Laparoscopic TAPP approach for a Nyhus IIIb inguinal hernia in a male patient

1. Clinical case presentation 00'17''

This is the case of a 38-year-old male patient with a normal BMI of 25. This patient was complaining of a symptomatic right inguinal hernia. It’s a primary hernia and he has no specific major previous medical or surgical history. A TAPP approach is chosen.

2. Trocar placement 00'41''

It is an easy case, male patient, slim. I will use a trans-abdominal preperitoneal approach with 3 trocars; one optical port, and 2 working ports. The optical port was introduced using a mini-open technique in a supra-umbilical incision and the 2 other trocars will be introduced on the right and left side on the mid-clavicular line at the level of the umbilicus just a little above on the side of the hernia and just under this horizontal line through the umbilicus on the mid-clavicular line on the left. We did a panoramic exploration after introduction of the 1st optical trocar to verify that there is no contralateral hernia. There was not so we decided to put the trocar exactly where I said before.

3. Diagnostic laparoscopy and landmark identification 01'49''

I use first a large view to obtain more information and get a panoramic view reducing the field of view and also a closer view of the anatomy. As you can see, the patient is in a supine position with both arms alongside the body, and a little Trendelenburg to expose the pelvis and the inguinal area without the use of a retractor. This is the left, the right umbilical ligament. In between, we have the urinary bladder. We don’t put a urinary catheter but the patient urines first before. The spermatic cord is visible inside the internal ring of the inguinal canal, and medially, there’s the spermatic duct and the spermatic vessels laterally. And you see the spermatic duct is crossing the umbilical artery. This will be the posterior limit of the dissection. This is the triangle of pain where we find a lot of nerves running and the danger is to dissect the nerves. We see a lot of nerve branches running through the peritoneum in this thin patient. I will begin. It is an indirect inguinal hernia. It is a Nyhus type III, and not a type II because the internal ring and external ring are visible with a 0 degree scope introduced through the umbilicus. You can see both holes.

4. Peritoneal flap dissection 03'40''

Doing a taxis first medial to the anterior superior iliac spine on the right and I do a tattoo to know exactly where it is. At this level, I have the tattoo here and there. This way I’ll do the incision. So I begin on the right doing the incision of the peritoneum, only the peritoneum, pulling a little to use the pneumodissection of the preperitoneal space. You can see I’m pulling back continuing the incision. And because I’m pulling, I can see better the limit of the incision. You see where the nerves are running, they are not far; the nerve is behind. It’s why it’s necessary to pull on the peritoneum. And the 1st step is to separate the retroperitoneal structures close to the peritoneum. And we continue the dissection laterally until we reach the lateral side of the spermatic vessels to find the right plane. It is necessary to use very soft and sharp dissection. Now we continue medially to find the right plane. We respect the embryological anatomy. So I did a lateral dissection in the Bogros’ space. Now I do it in the Retzius’ space. I continue the dissection mainly using traction and counter-traction. This is the pubic symphysis. I have to finish the dissection removing the hernia sac, the obturator vessels sorry. Now I will begin the dissection of the hernia sac. I will do the same, pull slowly and separate. You see this is the lateral wing of the spermatic sheet. And soon we will see the spermatic cord coming. Slowly we have to maintain the traction. This is the most difficult step. As mentioned earlier, it is not necessary to remove all the sac but I’m not far at this moment. This is the vas deferens. It looks like the end of it. I think I have all the sac. I’m doing the parietalization of the spermatic cord. There are vessels laterally and vas deferens medially. We see it now. As said before, I’ll dissect it to achieve a complete parietalization back until it crosses the umbilical ligament, artery. I have finished the dissection. You see when we have a bleeding, if we coagulate too deep, there’s a risk of nerve injury. So don’t coagulate with pressure on the muscles on the nerves. I try to stay at a distance catching the structures. I have finished the dissection of the preperitoneal space. We have opened Retzius’ space, Bogros’ space. We have freed the peritoneum from the cord and we have dissected the hernia sac and you will have the view after we have dissected. It’s clean. It’s now time to put the mesh.

5. Mesh insertion and fixation 10'00''

We are opening the mesh, it’s a 10 by 15. It’s a polyester multifilament manufactured by Covidien, 15cm in width by 10cm if we consider it’s the medial side. I’ll complete laterally and inferiorly to have a shorter lateral side. If you consider this will be medial, laterally I have reduced for the passage of the cord. And I roll the mesh from lateral to medial, and from anterior to posterior like this. I introduce the mesh through the 10mm trocar towards the Retzius’ space; as you see, we have the mesh rolled and the mesh unrolled spontaneously due to the memory from medial to lateral. Remember that I have opened the peritoneum very high; I can complete the dissection at this moment to put the mesh. You fix it on the Cooper’s ligament. This is the iliopubic branch, and fix it just above. It goes laterally towards the anterior superior iliac spine to virtually reconstruct the inguinal ligament. Then I’m fixing the mesh. You’ve seen the tacker that was not fixed. I will remove it. Don’t fix in the epigastric vessels. You see them there. We will fix laterally. And we can complete the fixation more medially.

6. Peritoneal mesh covering 13'00''

So we overlap the superior flap of the peritoneum. Do you not worry about the nerves more laterally with the tacker? If we respect the landmarks I gave, honestly we never had that sort of problem.