Laparoscopic Inguinal Hernia Repair
Laparoscopic Repair of Inguinal & Femoral Hernias
TAPP Repair: The Technique
Difficulty Level = 6 - MODERATE
A sub-umbilical incision (midline-2cm) is made.
Using "Army-Navy" retractors, the sub-cutaneous planes are retracted until
the linea-alba and the anterior rectus sheaths are exposed. A 2 cm
incision is made on the anterior rectus sheath, off the midline (on the
affected side). The rectus muscle and its most medial aspect is
Using a finger and blunt dissection, a tunnel is
created and the USSC dilating trocar is inserted.
The insert of the trocar is removed and replaced by
the 0 Deg. Telescope. Under direct vision, the balloon is inflated with
the hand pump.
The balloon is inflated, opened
When the balloon is totally unfolded [the balloon
will look "unwrinkled'], the telescope is removed and the balloon
deflated. The dilating trocar is then removed. The pro-peritoneal space
has been created.
Creating the Pneumo-Pro-Peritoneum
The structural 10 mm USSC trocar is inserted in the
same position of the dilating trocar.
Using the hand pump, the structural balloon is
inflated. It is then secured by sliding the adjustable outer ring of the
trocar to seal the entry site.
The insufflation port is connected to the
insufflation Pump. A pneumo-pro-peritoneum is created.
Two 5 mm Versaports are
inserted under direct vision. Although some surgeons place these trocars
in the midline [2cm and 4 cm below the umbilicus / midline], we favor the
lateral placement of these trocars [identical placement as in a TAPP
repair]. However, in most cases the dilating balloon does not extend and
push the peritoneal layer superiorly enough to safely place these trocars without
entering the abdominal cavity. Using the telescope, the
dissection of the peritoneum is bluntly extended superiorly. Once the first 5 mm trocar is
inserted a blunt grasper is used to perform the same maneuver on the other
If a peritoneal defect is created at this time it
should be immediately closed [see "Closing Peritoneal Defects during a TEP
The anatomical landmarks are identical when
performing a TAPP repair. However, the view is not as "clean" as
in a TAPP repair. Therefore, it is essential for the surgeon to get familiar with the
actual pro-peritoneal view as seen in the picture below.
The entire area should be meticulous and
bluntly dissected starting from the pubic ramus [easily
identifiable landmark]. Cooper's Ligament, the
Inferior Epigastric Vessels, the Spermatic Cord and the
position of the iliac vessels are clearly identified.
Dissecting the Inguinal Sac
inguinal hernia sac should be dissected carefully from the Spermatic
Cord. Direct hernia sacs are easily dissected. This is done by
gentle traction with atraumatic graspers.
Deploying and Anchoring the Mesh
The Mesh is rolled like a cigarette and inserted via the 10-5mm
Structural Trocar , uncut into the
pro-peritoneal space and deployed over the inguinal region.
Our current mode of placement of the mesh
is the "onlay Mesh Placement" which cover the entire inguinal region. The graft is
first attached or secured to Cooper's Ligament, and the superior
aspect of the pubic ramus using the Protackô
Instrument. The Mesh is then tacked on the posterior aspect of the Linea
Alba. The anchoring is continued around and lateral to the
Inferior Epigastric Vessels.
Caution: Do not place staples or tacks over the inguinal vessels.
A few tacks are used to staple the Mesh
lateral to the internal ring.
The Mesh should gently and generously
cover the Iliac Vessels without major gaps.
Testing the Fixation of the Mesh
The operator should check the Mesh is
well anchored to the surrounding structures. Using a closed grasper, pressure
is applied with the end or tip of the grasper directly
at the center of the covered direct and indirect defect. The Mesh should not
migrate and remain in place.
Completing the Repair
The pro-peritoneal space will be checked
for any peritoneal defects. If any, they should be closed using a SURGICON
Springlock. The 5 mm trocars are removed under direct vision.
The pro-peritoneal space will collapsed.
If there are any question about a missed
peritoneal defect, a completion laparoscopy should be performed.
The structural balloon is deflated. The
trocar is removed and the fascial
defect closed with the appropriate suture. The skin edges are approximated
in the usual manner.