Laparoscopic TAPP procedure for bilateral inguinal hernia

This video demonstrates the trans-abdominal preperitoneal (TAPP) approach to bilateral inguinal hernia in a male patient with a BMI of 55. The surgeon performs the repair using a non-woven, non-absorbable polypropylene mesh. The author uses a 3-trocar approach: the first one is a 12mm supra-umbilical port (i.e., the trocar for the scope), and two 5mm ports on the right and on the left approximately at the crossing between the umbilical line and the mid-clavicular line. A clear explanation of all surgical landmarks is offered. The main objectives when doing a TAPP dissection are well exposed.

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Laparoscopic TAPP procedure for bilateral inguinal hernia

Authors

J Leroy, J Marescaux

Abstract

This video demonstrates the trans-abdominal preperitoneal (TAPP) approach to bilateral inguinal hernia in a male patient with a BMI of 55. The surgeon performs the repair using a non-woven, non-absorbable polypropylene mesh.
The author uses a 3-trocar approach: the first one is a 12mm supra-umbilical port (i.e., the trocar for the scope), and two 5mm ports on the right and on the left approximately at the crossing between the umbilical line and the mid-clavicular line. A clear explanation of all surgical landmarks is offered. The main objectives when doing a TAPP dissection are well exposed.

Classification

basic techniques

Keywords

Laparoscopic TAPP procedure, bilateral inguinal hernia

Media type

Surgical video

Duration

18'00''

Publication

2009-04

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E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2527.htm

Laparoscopic TAPP procedure for bilateral inguinal hernia

1. Clinical case presentation 00'08''

We present the case of a bilateral inguinal hernia repair using the trans-abdominal preperitoneal approach. This is a 48-year-old male patient with a BMI of 55, presenting with a bilateral hernia. Three ports are used. The patient is in a lithotomy position, both arms alongside the body. The urinary bladder is emptied before without a urinary catheter. The patient is required to urinate before entering the operating room. Here’s the pubic symphysis, the midline, the rib, the left and right anterior superior iliac spine, the right and left mid-clavicular line and the horizontal line at the level of the umbilicus. I have positioned 3 trocars: the first one is a 12mm supra-umbilical port (it’s the trocar for the scope), and two 5mm ports on the right and on the left approximately at the crossing between the umbilical line and the mid-clavicular line.

2. Abdominal cavity exploration and hernia identification 01'14''

We explore the abdominal cavity and we are on the left side, and the omentum is inside the left hernia sac. There’s nothing on the right. We put the patient in a slight Trendelenburg. My objective when doing a TAPP dissection is not to dissect the sac.

3. Identification of landmarks 01'50''

First I have to determine the superior limit and the external limit is the anterior superior iliac spine. I’m doing a taxis and medial to this, I determine the limit. I will do a tattoo and then we’ll do a horizontal incision. I’m changing position to show you the medial tattoo. I’m using a circle incision, and I’ll begin laterally.

4. Right peritoneum incision 02'42''

I’m placing traction and I’m doing an incision of the peritoneum, only the peritoneum, and because I’m exerting traction, there’s a pneumodissection of the preperitoneal space. I’m continuing from right to left and you can see the plication of the peritoneum, and I’m joining my landmarks. I have finished the vertical incision. This incision is carried out from cephalad to caudad in order to show you that we have to dissect close to the peritoneum.

5. Right spermatic cord dissection 03'30''

We push only as you can see and we reach the lateral wing of the spermatic cord. I’m freeing slowly using two fingers to dissect the space. If you’re in the right embryological plane of the fascias, you’ll open easily the space. The pubic symphysis is just anterior to the scissors. This is the venous plexus of the Retzius’s space. If you dissect too close, you must remember that behind sometimes there are nerves and vessels running anteriorly. Because the transversalis fascia is the posterior wall of the inguinal canal. See here the iliopubic branch, the pubic symphysis. Sometimes there are big vessels, anastomosis between epigastric and obturator vessels. Now we have to free the vas deferens visible here close to the scissors in order to separate it from the peritoneum and do a complete parietalization of the cord. See the vas deferens; the right embryological plane is to be found here lateral to the urinary bladder. The vas is dissected till it is crossing the umbilical ligament. I’ve finished to dissect the spermatic cord. We can complete on this side in order to further free the edge and have sufficient space to place the mesh so that it covers this area largely. This is the transversalis fascia.

6. Right transversalis fascia reversion and fixation 06'21''

One of the techniques to avoid seroma, particularly in direct hernias, is to revert the transversalis fascia and fix it to Cooper’s ligament, which is this white structure. We use a stitch for fixation. It is not the treatment of the hernia, but a reinforcement. We are sliding on Cooper’s ligament. We can do exactly the same fixing the transversalis fascia back to the rectus muscle’s aponeurosis. So I’m changing my position because to do the procedure, it’s necessary to be on the opposite side of the hernia. Remember the triangle of Doom between the spermatic vessels laterally and the vas deferens. You have another triangle here, which is the triangle of pain. In this area, you find a lot of nerves running, iliac artery, the iliac vein is more medial and posterior, it’s exactly what you have when you have dissected. This is a beautiful triangle and don’t staple in this area. You can only do so on Cooper’s ligament and the anterior wall. But not only the fixation, if you coagulate too much because you have bleeding. For example, if you use bipolar coagulation, the danger is high. Remember I began laterally on the other side, because I’m right-handed so I prefer to incise from right to left. We use a sterile soap for cleaning purposes, the right trocar.

7. Left side peritoneum incision and dissection 08'58''

I am going to the left side and the trocar is not that easy to move. Usually when we have a fixed sigmoid with an inguinoscrotal hernia, it is a sliding hernia and it is difficult to reduce both because they are fixed together by a natural adhesion between the root of the sigmoid and the peritoneum. The best is to perform a large incision above and reduce the hernia sac as you would do for a TEP. Where I am doing my incision now, on the Douglas’ arch, that is the superior limit of the transversalis fascia. The best is to begin posteriorly, at this level, it is an easier way to find the right plane. Close to the peritoneum, that is the key. These are the spermatic vessels, the spermatic duct, this is the limit. I have to free the peritoneum. My guideline is the peritoneum, and you see finally we have nerves around the spermatic cord, deferential vessels, small nerve around, and we can understand the risk of pain if we dissect too much along the cord. I have now freed laterally, medially, and I can dissect the hernia sac. I think that because we do not have the possibility to place enough traction, the danger is to dissect immediately the hernia sac. The big lipoma we have is due to friction which in turn is due to the hernia. I suppose it is anterior not posterior and I cannot remove it because I have to open the transversalis fascia. On this side, there is a beautiful corona mortis. This is the anastomosis between the epigastric vessels and the iliac vessels, which we see here. It is coming from the iliac vessels, and the obturator vessels back to this. I will not dissect too much as it is not necessary. I will revert this and use the same technique with tacker.

8. Mesh preparation and placement 12'52''

The size is 27cm wide, 12cm in height medially and 8 cm, and I will roll the mesh from caudad to cephalad like this. I will not roll the last end, I will maintain this roll fixed and I will maintain this with 2 stitches, which are included in the mesh. It is a polypropylene mesh, a non-woven, non-absorbable one. It is very soft, I have designed the shape, and 27cm is the size we usually use. If we use 2 meshes, 15 by 15, we will do an overlap medially but you will see that normally it is perfectly adapted. When we have finished rolling it, I don’t roll the last 2cm of the superior portion, I plicate the mesh, grasp it medially, and introduce it through the 10-12mm trocar and into the abdominal cavity. In the middle, there is a line that we have marked, and we will fix it first.

9. Mesh fixation 14'30''

You see that I am fixing it, I do the same on the other side like this, and we will unroll it from caudad to cephalad. In surgery, if you prepare your work well, it is easier to finish and you gain time at moments like these. I think that in big hernias like these, it is necessary to fix the mesh.

10. Closure of peritoneum 15'33''

Now it’s necessary to close. You see the epigastric vessels, make sure you don’t fix these. We can use the hernia sac for a better cover. You have to close perfectly, if you fix the second, there is a risk of fistula too. Another problem is the risk of mesh migration, that is why we fix it, or reverting the inferior edge of the mesh and that’s why it is necessary to cover largely. One of the reasons why surgeons do TEP is that they control the position when they exsufflate.