Live surgeries of laparoscopic inguinal hernia repair: TAPP and TEP approaches

This video shows the TransAbdominal PrePeritoneal (TAPP) and Totally ExtraPeritoneal (TEP) procedures for inguinal hernia repair. These are live operations performed by Professor Joel Leroy (TAPP procedure) and Doctor Bernard Dallemagne (TEP procedure). The different technical details for each procedure are clearly exposed.

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Live surgeries of laparoscopic inguinal hernia repair: TAPP and TEP approaches

Authors

J Leroy, B Dallemagne, J Marescaux

Abstract

This video shows the TransAbdominal PrePeritoneal (TAPP) and Totally ExtraPeritoneal (TEP) procedures for inguinal hernia repair. These are live operations performed by Professor Joel Leroy (TAPP procedure) and Doctor Bernard Dallemagne (TEP procedure). The different technical details for each procedure are clearly exposed.

Keywords

Transabdominal preperitoneal approach, TAPP, totally extraperitoneal approach, TEP, laparoscopic inguinal hernia repair

Media type

Surgical video

Duration

32'41''

Publication

2010-05

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Audio

Subtitles

E-publication

WeBSurg.com, May 2010;10(05).
URL: http://www.websurg.com/doi-vd01en2992.htm

Live surgeries of laparoscopic inguinal hernia repair: TAPP and TEP approaches

1. TAPP approach: case presentation 00'16''

The case first, it’s a male patient as usual for inguinal hernia repair in 90% of cases, 40 years old, sportsman with symptoms of left inguinal hernia and we decide to do a laparoscopic repair as it is considered the best approach, particularly for sportsmen because we will see a rapid recovery and return to activity postoperatively.

2. External anatomical landmarks 00'47''

Here’s the pubis there, the xiphisternum, the midline with the umbilicus, the anterior superior iliac spine on the left and on the right, the anterior axillary line right and left, and mid-clavicular line on the left and on the right and the horizontal line at the level of the umbilicus.

3. Access and trocar position 01'11''

So we will begin using a mini-open technique through the umbilicus and we will put 2 other trocars on the mid-clavicular line on the right and on the left on the side of the hernia, above the horizontal line, on the opposite side under the horizontal line at the level of the umbilicus to have an arc circle disposition and to respect triangulation. I’ll just incise the skin and I’m grasping as you see the aponeurosis till I have opened the peritoneum, and introduce the One-step trocar inside it. Now I’m connecting the insufflation system and I begin the exploration. I’m verifying that I’m inside the abdominal cavity and I can insufflate because I’m sure now, not opening too much and slowly you’ll see the possibility to explore the abdominal cavity. We begin by an exploration of the lower part. You see on the right and we know that there was appendectomy adhesions. It doesn’t seem that there is hernia; there are some nodes just here under. We have on the left an inguinal hernia and we’ll explain more later. First I’ll ask the nurse to put the patient head down to have a better exposure so I’m putting as I said and I’ll show you, my trocars. I can put my finger to have a guard to protect and I can push under laparoscopic control and we can verify by transparency that there are no vessels where we put the needle, and we introduce the trocar.

4. Internal anatomical landmarks 03'40''

We see there that there are 2 veins and one artery between, these are the epigastric vessels not perfectly visible because due to the hernia defect we have attraction of all the structures. Normally it is like this. We have a virtual structure; this is the urinary bladder; we have the superior limit; medially sometimes we have a vertical structure that is the urachus we don’t see there, and the pubic bone with a spine that is the limit, the internal insertion of the inguinal ligament, and the external insertion of the inguinal ligament is the anterior superior iliac spine and I use external taxis; it is not far from there, and we have a virtual line between both, that is the line of the inguinal ligament. Under this line, this is what we call the triangle of pain: it is a triangle in which we have a lot of nerves running and the danger is to injure the nerves and to have postoperative pain and chronic pain at distance. Another triangle is created by the spermatic vessels as you see there and the vas deferens duct: this is the Doom triangle and the danger is to injure the big vessels. It’s why it is called the triangle of Doom. No fixation of mesh on both areas. This is the defect lateral to the epigastric vessels. You see the epigastric vessels are there and the defect is lateral. So it is an indirect inguinal hernia but it’s a type III according to Nyhus because it is similar to a direct hernia because there is no obliquity of the inguinal canal because as you see with a zero degree scope introduced in the umbilicus we see the external ring and the internal ring of the inguinal canal. So there is no inguinal canal.

5. Opening of the preperitoneal space 06'10''

I’m now beginning the procedure. So what is the first goal? It is to open the preperitoneal space. We don’t dissect the hernia sac. It is a big error to dissect the hernia sac and for that I use a new landmark, the anterior superior iliac spine, and at the level I’m doing a taxis, I’m tattooing like this and I will do a horizontal incision. If I don’t know how to proceed, I can do a new taxis outside on the horizontal line at the level of the anterior superior iliac spine. The best is to begin as you see like this and I’m going in the direction of the tattoo I did on the anterior superior iliac spine area. See the line is done. I’m coming back medially to do a vertical incision like this and I’m beginning the opening of the preperitoneal space. See I’m beginning medially, not dissecting the hernia sac first. See I’m doing a medial dissection, opening slowly the space using traction and counter-traction like this and this is the iliopubic branch with a lot of big vessels running. I’m continuing my dissection laterally now in the Bogros’s space. On the right, I begin laterally and finish medially. I have to find what we call the lateral wing of the spermatic cord and as you see we can free slowly.

6. Dissection of the sac 08'16''

There are the spermatic vessels; this is the lateral wing of the spermatic cord. The most difficult thing would be probably the dissection of the sac. We will do it now. Why? Because it’s not always easy in case of very deep sac to free it. For that, we use good traction. The danger is for the spermatic cord. It’s why we have to free slowly. See the spermatic cord is there. Why do you think that slim patients like this one is easier than with fatty patients? Because it’s a danger, particularly when you have the hernia sac coming and it’s a long hernia sac because we can modify the orientation of the anatomical structures. I’m freeing slowly. It’s coming. I think this is the deep part of the sac I’ve just found. You see the sac. Joel, do you consider the complete dissection of the sac every time? When it’s easy, yes; when it’s complicated, it’s not always necessary. We can keep a very deep part in very huge hernias, particularly in case of inflammation. We can let the fixed part, it’s better than to have a seroma, hematoma, and we can keep. The risk is to have hydroceles but it’s limited to less than 5% proximally the sac from the spermatic cord and I’ll show you the different structures: these are the spermatic vessels, this is the umbilical ligament and I want to complete this and I want to free the duct from the peritoneum and the posterior limit as I said is the crossing between the vas deferens duct and the umbilical ligament or artery. The umbilical artery is there and the vas deferens duct here. This is the posterior limit of the dissection. There are always very small vessels along the vas deferens. What do you think of the risk of stenosis of the vas deferens due to cautery at this level? I don’t think it was described as a risk till now but it’s a good remark. We have to use a minimum of energy and we can dissect without cautery but sometimes it’s necessary. After bilateral hernia treatment, it is estimated between 5 and 10%? But it depends on the age of the patient. By anterior approaches, particularly if you put a mesh, if you have a shrinkage of the mesh around the spermatic cord, it is similar. So I have finished to dissect. When we have finished to dissect, you see that we have exactly the same structures I described. You see nerves running there. We will not dissect. We have respected as you see the retroperitoneal structures. We are at distance. We have done what Stoppa called the parietalization of the spermatic cord. Everything can be parietalized. We have the vas deferens duct there; we see better now because we have dissected and what I can show: these are the obturator vessels with the foramen obturator there, you see I will not dissect more. We have nerves, vein, artery. This is the artery, vein, and the nerve is behind.

7. Mesh placement 12'02''

So now it’s time to put a mesh to repair. I will not close the defect. It’s not necessary. In case of direct hernia, the transversalis fascia is reversed fixing the fascia to the posterior aspect of the rectus muscles or on the Cooper’s ligament. This is to reduce the risk of seroma. This is a polyester mesh 15 by 10, I think it’s enough in this case, I will modify a little bit the shape and I’ll show you using the shape lateral, medial, larger. And I roll the mesh from lateral to medial and from anterior to posterior. I have finished rolling and I’m grasping the inferior side, the medial edge. I’m introducing the mesh inside the mid trocar and I am putting the mesh like this, medially, maintaining with my left hand, and unroll the mesh from medial to lateral as you see. You see that the covering is large enough. I am now using a tacker, but an absorbable one.

8. Mesh fixation 13'38''

I begin with a fixation, but not on the vessels. See it is an absorbable tacker. I’m going lateral, just close to the anterior iliac spine to reconstruct the line of the inguinal ligament. Then I am fixing on the anterior wall, I can eventually fix on the symphysis, it is only to maintain the mesh. No tackers, no stitches on the area under the inguinal ligament. Now I have to finish to ligate the sac. I think that it is not necessary, sometimes it is very useful to complete the closure.

9. Peritoneal closure 14'32''

To close, we use overlapping, see where is the inferior limit of the superior flap. I am covering using overlapping. It is probably better to fix with absorbable tackers in a slim patient as in this case, or to fix with sutures, a running suture to avoid migration of the tacker through the skin as was described. We have to close perfectly for different reasons. Do you think there is a risk of herniation into the sac? No I don’t’ think so, it was not described. But if you have a doubt, you can ligate but if I ligate, I don’t ligate inside but outside before closing. And what do you think of everting the sac and fixing it on the parietal wall? No I don’t think it’s necessary. If I ligate, I will ligate subperitoneally. I don’t ligate inside the abdominal cavity because if I ligate inside the abdominal cavity, I have to resect but I don’t resect. Why don’t you take down the adhesions? No, I don’t think it’s a good idea to remove because you see the caecum is completely fixed and the danger is to contaminate eventually if you open the mesh.

10. TEP approach: introduction 16'27''

So what we’re going to do here is to change totally the concept, instead of going inside the peritoneal cavity, we’ll try to work outside of the peritoneal sac because we feel that this huge dissection that you’ve seen is good for knowledge of the anatomy but logically if you think that you are working only on the back of the abdominal wall, sometimes you have to question the usefulness of this huge dissection inside the peritoneum. So we are going to try to do a totally extraperitoneal repair. So the head of the patient is here; this is the pubic bone, you see the umbilicus, iliac spine on both sides, and this patient has a right inguinal hernia.

11. Subcutaneous fascia dissection 17'17''

You dissect the subcutaneous fascia so what I did here already is to open a little bit the anterior sheath of the rectus muscle, see it?

12. First trocar insertion and CO2 insufflation 17'32''

And what I’m going to do is just to introduce the first trocar and I’m not moving forward just because I want to check that I’m in the right position. You see this right structure is probably the posterior sheath of the rectus muscle. And then I’m pushing the trocar you see, and now that I’m sure that I’m in the right plane, I will inflate. I will try to progress towards my first landmark, which is the pubic bone and I’m following the light of my scope towards and my hand is driving the scope and progressively I’ll try blindly, I’d say, to get the contact with the pubic bone. Then we are entering the space and immediately you can see on the right side this structure, which is probably a direct inguinal hernia. So you see I’m inside so I’ll use a little bit of the scope to increase the space because I know I’m not in the bladder.

13. Pubic bone identification 18'42''

You see the pubic bone there. So that’s a very important landmark.

14. Second trocar insertion 18'47''

So now that I’m inside, I’ve created this little space, I’ll introduce a second port. It’s approximately 3 fingers above the pubic bone. Why 3? Because you have to imagine that your mesh will be covering this area, so not too close to the pubic bone otherwise you have some trouble while inserting the mesh so a little bit above the pubic bone. And that’s a 5mm port, and again I’m controlling from inside. And I have to respect exactly the direction not going on the side because Joël has shown you what the risks of the lateral structures are. What I’m looking for is the epigastrics and you can see that immediately I have the epigastrics there, so what I know because you know the anatomy, I’m inside of the epigastrics so I know that it’s a direct hernia, it means that there’s no vascular structures or structures of the cord within this direct hernia so what I can do is to reduce this hernia immediately.

15. Direct hernia identification and reduction 19'58''

See the fascia there so a direct hernia is very easy. See we’re inside the hernia so now I can’t stop here the procedure because I know that if I want to be efficient with my prosthesis, I have to dissect a little bit more to create the space for my prosthesis. See here if you’re starting the dissection there, you’re lost and you can convert to a TAPP so that’s very important to visualize the epigastrics because I know that I have to work below the epigastrics. That’s very important and it’s probably the key of success when you’re doing a TEP procedure. See I’m trying to work below the epigastrics progressively creating the space, small vein here, and this is probably the cord so what we should do is to check that there is no indirect hernia so I can see the peritoneum there and also the very important point is to find at this stage the cleavage plane below the epigastrics and between the abdominal wall and the peritoneum. So you’re using your left hand for dissecting for this side? Yes, and your right hand to hold the camera? That’s right. It’s easier doing that because you better follow the instruments dissecting? Yes, I think it’s quite comfortable because I know where I want to go. Do you think it’s possible for anybody? Sure, this is the peritoneal sac and you see just by blunt dissection I’ve created this little space between the cord and the peritoneum and once I’m inside there, I know I’m in the right cleavage plane, so again I’ll use my scope and you see that progressively I’m increasing the space. See the iliac spine is there. I’m towards the iliac spine with the scope and you see inside that I’ve a good space now and what I’m going to do is to open a little bit more this space to get some room for my prosthesis. It’s a little bit easier when you start to have 2 ports. So you see this is the umbilicus, my optical trocar.

16. Second trocar insertion 22'35''

So we’ll go a little bit below, just lateral to the midline and I will insert a second trocar. We’re coming back with the camera, see and I have to introduce my trocar in this part so very gently I’ll go in the direction of this channel controlling the insertion of your trocar. So you see my trocar is inside. So very important is really to have a good control on the insertion of the trocar. This is the cord; you have recognized the spermatic duct, see vessels, spermatic duct there. I’ll dissect a little bit to free this because I want my prosthesis to go a little bit up so that’s why it’s always interesting to dissect all the inguinal rings because you find different things and here you see this lipoma. So there’s a question: if you make a hole in the peritoneum, what do you do? Nothing, usually you can still work with that so sometimes if you have very fatty patients, that may be a problem and what you can do is to insert for example a Veress needle or something like that in the peritoneal cavity to release the pneumoperitoneum. Sometimes you don’t need anything. The problem is when you have the pneumoperitoneum, if you haven’t yet dissected this area, that’s sometimes a problem because you don’t have that much space so you have to have some experience to do it but once you’ve got the experience you know the cleavage plane and you go directly in the right plane and you can even work with the presence of this pneumoperitoneum. You see I’m freeing laterally because I know that my prosthesis has to go there. Here I can do some little touch of coagulation because I’m not on the psoas muscle. A bigger hole, it’s similar to a flap, it’s falling, you have no pressure. It’s true that the thing as Joel said that you can do once you’re in trouble with the TEP is to convert to a TAPP of course. It’s easier to begin by a TAPP. So my question is if you do an error at the beginning and you insufflate the peritoneum not the peritoneal space, you said that it’s sometimes more difficult if you have the peritoneum at the beginning of the procedure. What do you recommend, to exsufflate, to try to find the right plane or to convert to a TAPP? I would say that if you don’t have that much experience, just convert to TAPP, once you have enough experience, you can try to find the dissection plane by TEP, that needs a little bit more experience I have to admit. We know that TEP is more difficult than TAPP because there are very critical dissection steps and if you don’t respect that, then you are in trouble. I would say that it is for people that are a little bit more used to this posterior approach to the abdominal wall, and probably starting with some TAPP technique, once you are confident with that, you can move to TEP, which is more logical for an abdominal wall repair than the TAPP. So I think it’s step by step. So you see I have my cord, I don’t have to dissect it too much, I will just move the peritoneum a little bit up, the same way as Joël Leroy did for the TAPP, you find the same landmarks again, see with the vein, so I will clear a little bit up the Cooper’s ligament because I will use a fixation there if needed. This is a very precise surgery because you can imagine that if you are not respecting the cleavage plane, there are a lot of structures there, so it’s very important to be very careful while dissecting. You see that I am not using a lot of coagulation because I am probably respecting the cleavage planes, and when you do that, you don’t have big trouble with bleedings. Now I am moving on the side, you see that I have cleared this space, I can see my psoas. See the psoas muscle, I progressively have enough room. I still have this band there that I will cut. It can bleed a little bit so I am coagulating. It is just to get a good place for my prosthesis, I think I am done. This dissection is quite similar to the one you have seen with Joël, all the different anatomical points. Here, usually when you have totally extraperitoneal repair, sometimes you don’t need to fix the mesh, but when you have this big direct hernia, it is better to fix it because the risk is that the mesh migrates within the hole. The second point is that I will use the stapler to close this fascia on the pubic bone, the aim being to reduce the risk of seroma. You see that I am returning the fascia on the pubic bone. That is very important because usually the rule for this direct hernia is to have a seroma postoperatively, every patient. I have the fascia in my hand and I will plug it on the pubic bone. As I have a lot of tackers, I will put two. So it is not hernia repair, it is only to avoid seroma? That’s right. Now I have enough space for my prosthesis, it is a polypropylene mesh, it’s the same size as Joël’s mesh.

17. Mesh insertion 29'37''

I put a line on it, I am not used to doing that but I think that when you start it is important because sometimes in the preperitoneal space you are a little bit lost. I will roll it like a cigarette, not like Joël. Initially I will try to put it laterally, on the psoas muscle there, and then I move to the pubis and I will place it down. You have to go a little bit below the pubic bone, you see there, and I will move back laterally. See I’m there on the psoas muscle, I have to deploy the mesh. Do you think you will have the possibility to deploy your mesh if you have a grip? Yes, I was used to working with this sort of mesh previously and it was not bad. It didn’t grip when you rolled it and unrolled it, or with glue integrated to the mesh, can you imagine how to deploy it and place it exactly in the right position? I think it is good for TAPP because you have a very large space, when you are inserting your mesh, for TEP you see that it is a little bit more difficult. You have to adapt a little bit the mesh to the size of the patient, but it’s important to cover properly. If you leave a short mesh, it’s done in two minutes, but the goal is to leave a very large mesh. You recommend a large covering, even for a small defect? Yes. That’s why it’s a little bit more difficult when you are dealing with a large mesh, but I think it is very important. People using very small meshes with big direct hernias and you find the mesh in the fascia. I am fixing, which is not usual for TEP, but it’s maybe because I didn’t roll this mesh in a very good position, now we are a little bit more free with these absorbable tackers, usually with non-absorbable ones I wasn’t very pleased with fixing the mesh. See the hernia was there, somewhere here, so we have a very large coverage of this area. Laterally we are covering the indirect ring, but you see the final coverage is quite similar to the one you got by TAPP. Now when I’m leaving the pneumoperitoneum, I will control the position of the mesh, making sure that I have no peritoneum going besides the mesh, that is very important. You see, deploying the mesh up there and it’s done.