Laparoscopic TAPP repair for a right Nyhus type IVa inguinal hernia in a male patient

Authors

Abstract

This edit of a case performed at a recent EITS Laparoscopic Course demonstrates the TAPP technique for a right inguinal hernia. As well as the technical steps, the relevant anatomy is expertly demonstrated.

Classification

routine cases

Keywords

recurrent hernia, Nyhus type 4a inguinal hernia, TAPP, laparoscopy, right inguinal hernia

Media type

Duration

10'32''

Publication

2008-07

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E-publication

WeBSurg.com, Jul 2008;8(07).
URL: http://www.websurg.com/doi-vd01en2367.htm

Laparoscopic TAPP repair for a right Nyhus type IVa inguinal hernia in a male patient

1. Case presentation 00'20''

You will have a demonstration of an inguinal hernia repair, laparoscopic TAPP approach.

2. Trocar positioning 00'40''

This is a slim male patient, with a recurrent hernia, herniorrhaphy using an anterior approach. For the landmarks, there is the pubic bone, right and left anterior superior iliac spine, the vertical line through the umbilicus, the horizontal line through the umbilicus and two other continuous vertical lines, you have to judge the position of the trocars after we have insufflated on the mid-clavicular line. First, we introduce the umbilical trocar just above the umbilicus, on the side of the hernia, this is a right hernia, we introduce the trocar above the horizontal line and on the other side underneath to respect the arc of a circle between the hernia and the position of the trocars.

3. Case commencement 01'50''

The first step is to undertake a panoramic exploration, we explore the inguinal area, with the umbilical ligament we see now, we don’t see a hernia but we see an edema.

4. Anatomical landmarks 02'10''

Concerning the repair, what are the landmarks to begin a TAPP approach? Anterior superior iliac spine, with external palpation I will do a tattoo using electrocautery.

5. Peritoneal dissection 02'30''

I will then do a horizontal incision like this, opening the peritoneum. You will have difficulty seeing what you do in the peritoneal space, it is better to incise more anteriorly and higher. I am grasping the peritoneum and now I will begin the procedure. Because I am pulling on the peritoneum, there is a landmark coming into view and I use the pressure of the pneumoperitoneum to incise. To complete this, I am grasping the umbilical ligament using my scissors to incise vertically and join the horizontal incision.

6. Development of preperitoneal space 03'30''

I have finished incising, you see that I am grasping the peritoneum using traction and counter-traction, you see the transversalis fascia with the Douglas’ arch. I am using traction and counter-traction, followed by action! I am reaching the iliopubic branch and you see the Cooper’s ligament. I will not dissect more, it is not necessary to see the Cooper’s ligament so well, only to show you where it is. This is the symphysis of the pubis, this is the right iliopubic branch, the obturator hall is not far, just behind there, we will complete before the dissection of the peritoneum, we have to be careful not to open too much.

7. Dissection of hernial sac 04'50''

We are dissecting a lipoma now probably and the hernia sac too. This is a lipoma due to the traction. I am freeing the spermatic vessels that are running towards the internal ring of the inguinal canal, we will see it better later on. This is the vas deferens, spermatic vessels, iliac vessels, you see a marvellous nerve, I think it is a femoral nerve, iliac vein, spermatic cord, we will dissect it up to the limit of the dissection. It is a crossing between the umbilical artery and the spermatic cord. We have the spermatic vein there, the iliopubic branch covered by the fatty tissue; if we want to see better, these are the obturator vessels. We have dissected enough posteriorly and we will put a mesh.

8. Mesh preparation and placement 06'28''

I use a 15cm large mesh, 12cm high medially and 8cm laterally. This is a polyester mesh 15 by 15cm, parietex mesh, but we will shorten the mesh by reducing it to 12 by 15 first. This will be lateral, this medial, so laterally I complete this, I am doing this shape of mesh. The iliac vessels will be like this and I will put my mesh. I roll it from lateral to medial and from anterior to posterior. I grasp the extremity of the mesh and I introduce the mesh inside the abdomen in the direction of the space, you see the mesh is in the right position, we maintain it with one of the forceps and due to the memory of the mesh, we position it like this to largely cover the inguinal area and we will fix the mesh using tacker.

9. Mesh fixation 08'10''

Now I have to fix on the Cooper’s ligament, I recognize it because there are structures like this, then I go lateral in the direction of the anterior superior iliac spine. This is as the inguinal ligament, it is in half it’s ok, we can fix it on the symphysis. Then we have to close.

10. Re-approximation of peritoneum 08'50''

And to close we overlap the peritoneum, the inferior flap covers the superior one, and we close step by step. Some changes to the intraperitoneal pressure to close this window? Not in this case, I don’t think it is necessary because we have a good opening. Sometimes you need to reduce the pressure? Yes, when there is tension it is sometimes necessary. You can use your hand to complete. Now we can reduce the pressure.

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