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Recurrent indirect inguinal hernia after laparoscopic TAPP: a new TAPP repair

Authors

Abstract

This video demonstrates a TAPP repair for a doubly recurrent inguinal hernia. The difficulties encountered due to the previous attempts at repair are shown as well as how they are supervened.

Keywords

TAPP repair, laparoscopy, doubly recurrent inguinal hernia, recurrent indirect inguinal hernia

Media type

Duration

06'18''

Publication

2008-03

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E-publication

WeBSurg.com, Mar 2008;8(03).
URL: http://www.websurg.com/doi-vd01en2297.htm

Recurrent indirect inguinal hernia after laparoscopic TAPP: a new TAPP repair

1. Illustration of case principles 00'15''

This video shows the laparoscopic approach of a right doubly recurrent inguinal hernia. The patient had a right inguinal hernia that was initially repaired by a TAPP technique. Months afterwards he consulted for an inguinal mass on the same side, and a recurrent hernia was diagnosed. On this second repair, an open technique was chosen. The patient then had a third recurrence diagnosed clinically and by ultrasound and a laparoscopic approach to the repair at this time was performed. The following diagram shows the technical principle of the previous surgery. With the laparoscopic approach, we expect to easily distinguish the anatomy of the inguinal region.

2. Peritoneal incision and tissue dissection 00'51''

The mesh was placed in a higher position than usual, and therefore a defective inguinal repair allowed the sliding of the bowel loops through the defect and hence a recurrent hernia. The surgery started by an incision of the peritoneum from the right superior anterior iliac crest up to the umbilical ligament on the midline. Dissection then continues medially up to Retzius’s space. We encounter significant fibrotic reaction en route due to the previously placed mesh. In this case, lateral dissection was performed in front of the mesh, and you can see that dissection is difficult due to the scarring. We then continued downwards searching for the spermatic vessels on the preperitoneal space.

3. Dissection of hernial sac 02'48''

Dissection of the hernial sac was carried out respecting the elements of the inguinal canal. The identification of the spermatic vessels and the vas deferens is of course mandatory.

4. Suture closure of deep inguinal ring 03'30''

Having dissected these elements, a simple suture was placed on the deep inguinal ring in order to obliterate its lumen.

5. Mesh placement 03'47''

The diagram shows the new mesh position, and you can see the previous hernial defect. The mesh is placed intra-abdominally and unrolled laterally. It is then fixed to the anterior abdominal wall, Cooper’s ligament and the pubic symphysis.

6. Re-approximation of peritoneum 04'34''

Afterwards, the mesh had to be covered by peritoneum so as to avoid contact with bowel loops and to reduce the risk of fistula formation. Adequate fixation is accomplished using metallic tacks. The mesh remnant then had to be resected and a final repair of the peritoneum was performed by simple suturing.

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