TAPP approach for recurrent inguinal hernia after a plug hernioplasty

This video demonstrates a laparoscopic TAPP repair in a patient with a recurrence after a previous plug repair. The surgeon mobilizes the hernia sac and identifies the key structures using a TAPP approach. The procedure is similar to standard TAPP technique. No attempt is made to remove the plug and a prolene mesh is used to cover the hernial region and is anchored to the lacunar ligament, pubic tubercle and the under surface of the abdominal wall. The peritoneum is then covered over it.

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TAPP approach for recurrent inguinal hernia after a plug hernioplasty

Authors

M Simone, J Marescaux

Abstract

This video demonstrates a laparoscopic TAPP repair in a patient with a recurrence after a previous plug repair. The surgeon mobilizes the hernia sac and identifies the key structures using a TAPP approach. The procedure is similar to standard TAPP technique. No attempt is made to remove the plug and a prolene mesh is used to cover the hernial region and is anchored to the lacunar ligament, pubic tubercle and the under surface of the abdominal wall. The peritoneum is then covered over it.

Classification

complex cases

Keywords

recurrence, laparoscopic hernia repair, TAPP procedure, mesh, hernia plug

Media type

Surgical video

Duration

07'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1700.htm

TAPP approach for recurrent inguinal hernia after a plug hernioplasty

1. Case presentation 00'08''

This video shows the transabdominal preperitoneal approach for recurrent groin hernia after hernioplasty with a plug. This is the case history of a male patient presenting with a left recurrent hernia. A hernioplasty was performed 2 years ago utilizing the Rutkow technique. The patient has noticed during the past 6 months a recurrent mass in the left inguinal region despite this open repair.

2. Operating room set-up 00'33''

The patient is supine on the operating table. The surgeon stands to the patient’s right side opposite the hernia. The assistant faces the surgeon on the left and the scrub nurse stands to the right of the surgeon. The laparoscopic unit is located at the patient’s foot. The patient is placed in a Trendelenburg position with a 5 to 10 degree tilt of the operating table to aid with small bowel mobilization out of the pelvis improving exposure.

3. Trocar placement 01'00''

Three trocars are used. One trocar is positioned at the umbilicus level. A 5mm trocar is placed in the right flank and another 5mm in the left flank.

4. Peritoneal incision and dissection 01'14''

The procedure starts with laparoscopic exploration of the inguinal region. A recurrent hernia is noted on the left. A loop of the sigmoid colon can be seen protruding into the hernia. The peritoneum is opened cephalad and lateral to the site of hernia recurrence. The peritoneal incision is extended up to the anterior superior iliac spine. Detachment of the peritoneum is carried out, thereby freeing the preperitoneal fat from it. Care should be taken to avoid injury to the colon during mobilization of the peritoneum as you can see the close association of the two here. The pubic region is freed medially. Here you can see the hernia sac.

5. Hernia sac disection 02'02''

We continue with sharp and blunt dissection and mobilize the sac. You can also see the previously placed plug in this area. We keep the plug in place as further dissection in this area is not required. Dissection continues once we have identified the pubic bone, which is the point of medial dissection and utilized in anchoring the mesh. With blunt and sharp dissection we slowly began to dissect the hernia sac away from the preperitoneum. Here the edge of the sac is clearly delineated. Sharp dissection is then undertaken. The pubic bone medially and the spermatic vessels are now noted. The plug is once again noted here. The following landmarks should be observed: internal inguinal ring, spermatic vessels, the vas deferens as well as the aforementioned pubic bone.

6. Mesh placement 04'17''

The danger areas are the triangle of Doom, which is lateral to the spermatic vessels and the vas deferens as well as the triangle of Pain as noted here. Once the peritoneum has been fully dissected, a new polypropylene mesh is introduced and placed over the hernia defect. The mesh is then folded after it is inserted into the abdomen. We use the mesh from Ethicon Endoroll. There are many different manufacturer supply of polypropylene mesh as well. We commonly have the size of 10 to 15cm in overall length to maintain a large enough mesh to decrease recurrence. The mesh is anchored at the level of the pubic bone medially with a tacking device. You can also use staples. We use a tacking device. However, a stapler will serve the same purpose and can be obtained with an additional function to aid in the angulation of the staple with the tissue. The mesh is then secured with tacks along the anterior abdominal wall taking care to avoid the danger zones. Caution must also be paid not to injure the epigastric vessels when securing the mesh.

7. Closure of peritoneum 05'35''

Once the mesh has been secured in place, we reperitonealize the inguinal region with the use of a tacker. The stapling device or suture can also be used in this task particularly to save cost when doing a bilateral hernia repair. The staples or tacks are often used up securing the mesh leaving the peritoneum without approximation unless one opens a second device or another stapler cartridge. Suturing can be utilized for this task and can be completed quickly with an absorbable suture. Once the reperitonealization is complete, this marks the end of the procedure.