Using laparoscopic TAPP approach for type IV Nyhus right inguinal hernia

Surgical repair of recurrent hernias is technically difficult and carries a risk of higher morbidity. The laparoscopic surgery allows a posterior assessment of the inguinal floor from a trans-abdominal approach, permitting an evaluation of the entire inguinal region and assessment of all potential hernia sites. We present the case a recurrent inguinal hernia managed by a TAPP approach.

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Using laparoscopic TAPP approach for type IV Nyhus right inguinal hernia

Authors

J Leroy, J Marescaux

Abstract

Surgical repair of recurrent hernias is technically difficult and carries a risk of higher morbidity. The laparoscopic surgery allows a posterior assessment of the inguinal floor from a trans-abdominal approach, permitting an evaluation of the entire inguinal region and assessment of all potential hernia sites.
We present the case a recurrent inguinal hernia managed by a TAPP approach.

Classification

routine cases

Keywords

laparoscopic TAPP approach, type IV Nyhus right inguinal hernia

Media type

Surgical video

Duration

10'15''

Publication

2009-01

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E-publication

WeBSurg.com, Jan 2009;9(01).
URL: http://www.websurg.com/doi-vd01en2530.htm

Using laparoscopic TAPP approach for type IV Nyhus right inguinal hernia

1. Clinical case presentation 00'17''

This is a case of right side inguinal hernia recurrence operated using an anterior approach with a double mesh (anterior and posterior parts). The anterior part was removed and there’s a clinical recurrence. I will use a TAPP approach. I think it’s not a bad idea to do a TAPP in case of posterior mesh and recurrence with a posterior mesh. Probably there’s a consensus for this type of hernia when we do a laparoscopic posterior approach and the Stoppa procedure.

2. Trocar position 01'54''

We use 3 trocars: a 12mm one optical port introduced supra-umbilically, two 5mm trocars (number 2 and 3) approximately at the level of the umbilicus, but just above on the side of the hernia at the crossing with the mid-clavicular line and on the other side under the horizontal line, but not too much, 1 or 2cm. Normally if it’s bilateral, I put them both at this level. I did a small incision using the mini-open technique. I have found a small umbilical hernia just above and I have included the incision in the small hole of the hernia.

3. Anatomical landmark description 03'04''

We start by doing a panoramic exploration. We use a small Trendelenburg to help in exposure and we verify that there is no hernia on the other side and there is none. We can see the vas deferens, spermatic vessels, the internal ring of the inguinal canal, the epigastric vessels (one artery and 2 veins), the muscles and the nerves, this is the internal femoral nerve, and the umbilical artery and ligament, and a small hernia just under a scar, the spermatic duct, spermatic vessels, psoas muscle, the inguinal region.

4. Peritoneum flap dissection 04'23''

We’ll begin the procedure with a few landmarks, the anterior superior iliac spine. We begin with an incision. We don’t dissect the hernia sac. We incise the peritoneum. As you can see, it’s a slim patient. I’m doing a vertical incision to have a better flap. We come back on this side. We complete the incision lower the peritoneum from the retroperitoneal structures and you can see this is a scar we have from a previous surgery. It doesn’t seem that there is a mesh visible till now. It’s unusual to have an indirect recurrence. It’s interesting that you don’t see a mesh because in the history they had a preperitoneal mesh placed. That’s the mesh. I will not touch more because medially it’s well covered. The mesh was mainly medial. I have to free the spermatic vessels now. The danger in case of recurrence is for the spermatic duct. We can see it now. We will try to free the peritoneum. We have it now. If there was a mesh on this side, would you remove it? No, we don’t. We use the part of the mesh that is covering the weakness of the inguinal area and we complete the covering with another mesh. It’s not necessary except if there is irritation of nerves, but if it’s only for a recurrence, we complete the covering. It’s the ideal way of doing recurrences. I’m dissecting till the vas deferens is crossing the umbilical artery. Pull like this: the crossing is there above. It’s a posterior dissection. I have finished dissecting the preperitoneal space. You can see the spermatic vessels.

5. Mesh placement 08'02''

Generally speaking, the mesh put in in a TAPP is not usually somewhat smaller than you put in in a TEP. This is a 15 by 10. We would tend to put in a TEP a 15 by 13. This again is a Parietex type mesh.

6. Mesh fixation 08'44''

You have seen we don’t do a dissection of the pubic bone, iliopubic branch. I fix on the Cooper’s ligament, then laterally, and now I can fix differently. One of the problems when we have recurrence, there’s a risk (even if we do a total preperitoneal approach) to have a very fragile peritoneum and scar. When we will exsufflate, it will be good. The intervention is complete now.