Bilateral inguinal hernia: laparoscopic TAPP repair, tips and tricks

Authors

Abstract

This video provides an excellent teaching demonstration of a laparoscopic transabdominal preperitoneal (TAPP) hernia repair.

Keywords

Bilateral inguinal hernia, laparoscopic TAPP repair, tips and tricks

Media type

Duration

20'22''

Publication

2012-01

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E-publication

WeBSurg.com, Jan 2012;12(01).
URL: http://www.websurg.com/doi-vd01en3556.htm

Bilateral inguinal hernia: laparoscopic TAPP repair, tips and tricks

1. Introduction 00'18''

I will show you the TAPP technique, that is the transabdominal preperitoneal approach that we performed laparoscopically. First, I want to highlight the different landmarks: we have the rib, the pubis, the anterior superior iliac spine, left, right, the midline, the umbilicus, anterior axillary line on the left, on the right, mid-clavicular line, left and right, and horizontal line at the level of the umbilicus. So the first step is to enter inside the abdominal cavity.

2. Trocars position 01'09''

First, I’m doing a supraumbilical incision, as you can see, to do a mini-open approach, so I’m dissecting until I’m reaching the aponeurosis and entering inside the abdomen. At this moment, I’ll introduce the sleeve of the VersaStep™ trocar and I’m pushing a 12mm trocar inside it. So now we are inside the abdomen. We check before insufflating and we insufflate now. You see I have done the exploration and there is a bilateral hernia so I’ll treat both. I have now 3 trocars as you will see, one 12mm trocar just above the umbilicus, and two others at the crossing between the mid-clavicular line and horizontal line through the umbilicus.

3. Anatomical landmarks 02'37''

So I’ll explain the anatomy now; you have a panoramic view of the pelvis on the left side, we have the sigmoid fixed and on the right side, we have no adhesions, no previous surgery as it seems. The anatomical structures we can see are: first one vertical: it is the umbilical ligament on the right, and we have the same on the left. Normally in the middle, you can have the urachus—not visible here. We have other vertical structures, not well visible, but it is Hesselbach’s triangle with the epigastric vessels-- we see them beating, they are huge; we have normally one artery and two veins; it is an obese patient and it is why we don’t see so well the structures. These are the spermatic vessels. We have another oblique internal structure that is the vas deferens duct. Both are going to the internal ring of the inguinal canal without hernia, it is only a small dehiscence but not a hernia inside the inguinal canal. Medial to the epigastric vessels, we see a big defect that is a direct inguinal hernia. This is a Nyhus IIIa. All the structures determine an area: posteriorly, you have a triangle formed by the vas deferens duct and the spermatic vessels: this is the triangle of Doom where you will find all the vascular structures with the external iliac artery, the vein behind we don’t see very well but you see the blue part, and laterally you have the femoral nerve. Lateral to the spermatic vessels and under the vertical line, that is the line between the pubic spine and anterior superior iliac spine where we have the inguinal ligament, we have another triangle that is called the triangle of pain where we have a lot of nerves running on the muscles and aponeurosis, that’s why it’s better to dissect close to the peritoneum. Above the inguinal ligament, you will have different areas; lateral to the epigastric vessels, we have the external inguinal area between the epigastric vessels and umbilical ligament, we have the middle inguinal area where we will find the direct hernia and under the inguinal ligament we have here,-- this is the inguinal ligament, we have the femoral hernia, and medial to the umbilical ligament and you see the urachus is there, this vertical structure, and lateral to the urachus, we have the internal inguinal area where we will find the direct hernia and indirect internal hernia. In this patient, we have found a defect and weakness of the transversalis fascia-- we’ll see it better, and a direct hernia, and as usual, when we have a direct hernia, we have perhaps not the beginning but not far, a direct hernia that is coming. It’s perhaps a weakness. So how I will proceed.

4. Opening of preperitoneal space 06'56''

I will open the preperitoneal space and I’m doing a small incision of the peritoneum medial to the anterior superior iliac spine as you have seen, and I’m continuing the incision vertically, and you see, thanks to the traction I’m placing with my forceps in my left hand, I can continue the incision horizontally, not obliquely. And the traction gives a line to do the incision. Only the peritoneum and I continue the incision vertically to have a view and easy flap when I’ll dissect the inferior flap. Can you show us from the external view the starting point and the end point? Yes, so I did the incision medial to the anterior superior iliac spine, and I will continue my incision horizontally. So now I’m doing the dissection of the peritoneum and the best is to begin as you see posterior to find the plane, not dissecting in contact to the muscle. This is the lateral wing of the spermatic sheet.

5. Dissection and parietalization of structures 08'49''

We see the color, we will free it later. This is what Stoppa taught us concerning the anatomy in order to do the parietalization. So I’m pushing this this way. We have the spermatic vessels but we have to free the lateral wing like this. It’s not necessary but to respect the anatomy perfectly, we have to proceed this way in order to do the parietalization of all the structures of the spermatic cord and we see very well this lateral wing progressively pushed. We have to stay close to the peritoneum and it’s like this that we’ll have the vas deferens duct soon. This is the vas deferens duct. We will dissect medially always using the traction that will facilitate the dissection of the space with a pressure of the pneumoperitoneum. Normally, we have to use the instrument as two fingers, to open the space and dissecting anterior to the perivesical fascia, it’s not necessary to open.

6. Dissection of Retzius\'s space 10'49''

I’m dissecting Retzius’s space and I am in front of the urinary bladder, and behind the symphysis of the pubis. I’m continuing medially to reduce the hernia sac. And we see very well through the epigastric vessels. For direct hernia, it’s very easy, and it’s a good indication for TEP, it’s easier, particularly for beginners. This is the transversalis fascia, I made a small error, I should not have to open it, because we have a subcutaneous emphysema, and it is not what I have to retract. Now I have to completely free the peritoneum from Hesselbach’s ligament and from the spermatic cord. So slowly we have finished to do the parietalization of the retroperitoneal structures, particularly of the spermatic cord as you see. Medially, the vas deferens duct, I’m offering posteriorly to the iliopubic branch, this is the iliopubic branch with Cooper’s ligament. I think we can do more, the best is to free the vas deferens duct until it is crossing the umbilical artery. On the back, you will see.

7. Fixation of transversalis fascia 13'00''

You see I have now the transversalis fascia, and the best to avoid a seroma is to reverse the fascia and to fix it to Cooper’s ligament. This is a Begin technique. So I will fix, we can fix with a suture, we can fix with tacker, I have fixed you see, this is not the treatment of the hernia, but we will not have defect. I think that particularly when we have a direct hernia, we have to evoke this possibility, because direct hernia is a problem of weakness, and particularly in adult male patients, it is rarely unilateral. When we have a direct hernia, it is probably true. For indirect hernia, it is not exactly the same, not that it’s not the same pathology, but the same etiology concerning the hernia. And we have a direct hernia, especially in young adults, it is one of the best indications for a laparoscopic approach to treat the hernia bilaterally. Don’t incise too deep because you will be on Douglas’s arch and you will incise the aponeurosis, not the peritoneum. I will fix here too. Usually you see the V of the vas and the vessel and when you have a large V, you can stop.

8. Mesh positioning 14'53''

So I have finished and I will put the mesh, one mesh on the right, one on the left, I can put a big bilateral mesh. It’s a 10x15 mesh and I will give a shape to have a 10x8 and changing like this. Is it a Prolene mesh? Yes it is. This is a Parietene, it’s not ultralight but it’s soft polypropylene. This is the right side, so we have lateral, medial, and now I’m rolling the mesh from lateral to medial, and anterior to posterior. Rolling like this, OK. Now I’m grasping the bottom of the mesh and introduce it inside the abdominal cavity in the preperitoneal space, I have had the tactile feeling of the pubic bone. We love this mesh because it is rigid enough to be in place and soft enough and you see, thanks to the memory of this mesh, we can put it easily and more recently there was a paper comparing the different types of meshes and no difference concerning the mesh for postoperative pain, but as we know, laparoscopically, some meshes are easy to put, others are not, particularly when they are too soft when there are some grip to fix, it is more difficult to manipulate, particularly for beginners. It’s not necessary to have a very expensive mesh because there is no advantage, there is a recent paper showing that. You see we have to put the mesh in the midline, we are at the symphysis of the pubis.

9. Mesh fixation 17'52''

The shape is perfect. I put now a tacker there, put another one close to the anterior superior iliac spine. This is as inguinal ligament, no tacker under the line, and we can continue to fix like this, using counter-pressure, not fixing the epigastric vessels, like this.

10. Peritoneal closure 18'31''

What we will do now is the closure, and we will do the same after on the other side, some tacker can injure, due to the position of tacker in the nerve, and postoperatively a typical immediate pain may occur. And you have to re-operate the patient immediately to remove the tacker that is responsible for the pain. I think you’d better use an absorbable one, because that can create pain. Not in the epigastric vessels as you see, I have to have to reconstruct the inguinal ligament to have a virtual line, you see we do an overlapping to have a suture with a tacker. And antibiotic guidelines? No we have a flash for all the patients we operate, but we don’t put postoperative antibiotic therapy. Thank you Joel, nice demonstration.

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