TAPP procedure for a right inguinal hernia (Nyhus 3a)

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TAPP   procedure   for   a   right   inguinal   hernia   (Nyhus   3a)

Authors
J Leroy, J Marescaux
Media type
Duration
15'00''
Publication
2005-05
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1785e.htm

TAPP   procedure   for   a   right   inguinal   hernia   (Nyhus   3a)

2. Opening of peritoneum 00'52''
Why direct? Because we are medial to the epigastric vessels and the spermatic cord here. I use 3 trocars, one 10-12mm trocar in a supra-umbilical position, and 2 lateral trocars on the mid-clavicular line, right and left at the level of the umbilicus. If it’s unilateral, we normally put the opposite trocars a little lower. In this case, we have to chosen to put them at the same level. We use trocars between 2 to 3mm in size, we can reduce the size of the lateral trocar; if you use larger trocars, there is a risk of pain because you have to close the trocar site with full closure of the aponeurosis. I’m using a zero degree telescope. I have put a landmark at the level of the anterior superior iliac spine, just medial to it to locate the area. I will then incise the peritoneum horizontal to this line until I reach the root of the umbilical ligament and I complete my incision vertically to do a L-shaped incision, G-shaped on the left, L-shaped on the right. Then I have to free the anterior space anteriorly to the peritoneum and not far from it to free the adhesions. The important thing is not to keep in front of the fatty tissue because sometimes people get in the wrong plane here. I’m not far from the hernia sac as you see. The patient is placed in a slight Trendelenburg with a 5 degree tilt. I have to work anteriorly to the peritoneum. So we dissect the space slowly. We have to stay between the embryological plane using traction mainly exerted with my left hand. This is the symphysis, the urinary bladder. We complete the freeing laterally. Don’t hesitate to incise very high, minimum at the level of the anterior superior iliac spine and not too anterior. You see that we keep the fatty tissue to cover the muscles. We don’t have to dissect close to the muscles. We’re not far from the spermatic vessels here. I have to remove the hernia sac first. You see the direct hernia with epigastric vessels here. The hernia sac is reduced, you’ll see the defect here. I have to free from the spermatic vessels and stay always close to the peritoneum. There is a little lipoma here but it’s not an indirect hernia. Here is the vas deferens. It’s important to remove this lipoma because the patients sometimes often think they have got a recurrent hernia. Indeed, this would simulate a recurrence postoperatively. Finally the sac is coming. We have to separate more. The spermatic vessels are on the right, here is the vas deferens. We have to dissect until we reach the crossing with the umbilical artery. It’s very important to dissect this right down otherwise the mesh doesn’t sit properly. We have to parietalize the spermatic sheet. I think that we have freed sufficiently. We will be able to place the mesh. The space is freed laterally. Why is it important to incise very high? Because we don’t have the curtain effect.