Transabdominal preperitoneal patch (TAPP) repair of inguinal hernia

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Anatomy of the inguinal region

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    Posterior aspect of the inguinal region: (1) Inferior epigastric artery and vein, (2) Medial orifice = direct inguinal hernia, (3) Femoral hernia orifice, (4) Pectineal ligament (Cooper), (5) Spermatic duct, (6) External iliac artery and vein, (7) Testicular artery and vein, (8) Iliopubic tract, (9) Lateral orifice = indirect inguinal hernia The inguinal region (where the anterior abdominal wall transitions to the lower extremity) possesses several weak spots, where a hernia sac (with or without contents) may protrude through the abdominal wall (femoral hernias are more frequent in women, while inguinal hernias are more common in men). Inferior to the inguinal ligament the septum of the iliopectineal arch divides the inguinal canal into a vascular and muscular compartment – lacuna vasorum and lacuna musculorum respectively. Vascular compartment

    • Both the external iliac artery and vein (→ femoral artery and vein; with the artery lateral to the vein) course through the vascular compartment which is lateral to the pubic bone. In addition, the femoral branch of the genitofemoral nerve passes through the very lateral part of this compartment, while the deep inguinal lymph nodes (Rosenmueller nodes) are located inferomedially. In femoral hernias the lacuna vasorum is the deep weak spot (through the femoral septum along the femoral vein).

    Muscular compartment

    • Lateral to the lacuna vasorum, the muscular compartment is traversed by the psoas major and iliacus muscles (together they comprise the iliopsoas muscle), the femoral nerve, and lateral femoral cutaneous nerve.
  • Anterior abdominal wall and inguinal canal

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    During testicular development the tubular structure of the inguinal canal is formed by the externalization of the testicles, which are pulled into the scrotum by the gubernaculum testis. The peritoneum pulled along during this descent remains in the inguinal canal as a pouch (processus vaginalis testis). Thus, the layers of the abdominal wall turn into the corresponding sheaths in this pouch: Transversalis fascia → internal spermatic fascia, internal oblique → cremaster, fascia of external oblique → external spermatic fascia, no investment by the transversus abdominis since it terminates more cephalad. The blood vessels (testicular artery and vein), spermatic duct (ductus deferens) and nerves (ilioinguinal nerve originating from the lumbar plexus) are also pulled into the scrotum, and together they form the spermatic cord. When the processus vaginalis closes, it obliterates the connection with the peritoneal cavity, typically leaving behind only the vestige of the vaginal process. In the female embryo the pull of the gubernaculum does not result in a complete descent of the ovaries, which remain close to the uterus, but rather the remains of the original gubernaculum persist in the inguinal canal as the round ligament of uterus. Incomplete obliteration of the processus vaginalis is a weak spot in the abdominal wall and therefore a possible starting point for inguinal hernia. The approximately 4 cm long oblique inguinal canal, slanting downwards and medially, parallels the inguinal ligament immediately superior to it, with the cephalic end of the canal originating at the deep inguinal ring and the opening to the external abdominal wall at the superficial inguinal ring.

    Deep inguinal ring

    • Halfway between the pubic symphysis and the anterior superior iliac spine in the inner abdominal wall, lateral to the inferior epigastric artery and vein (within the lateral umbilical fold)

    Superficial inguinal ring

    • Superior to the pubic tubercle in the fascia of the external oblique, anterior edge pointing cephalad, posterior edge formed by inguinal ligament, sides = medial and lateral crus with stabilizing intercrural fibers.
  • Walls of the inguinal canal

    Anterior wall

    • Fascia of the external oblique, with lateral augmentation by fibers of the internal oblique → inguinal ligament and → cremaster

    Posterior wall

    • Transversalis fascia, with medial augmentation by the conjoint tendon (= tendon of the transversus abdominis and internal oblique).

    Superior wall

    • Transversus abdominis and internal oblique (fibers running from inguinal ligament to the medial conjoint tendon)

    Inferior wall

    • Medial inguinal ligament (= reflected ligament) and a trough for the spermatic cord formed by the external oblique.
  • Contents of the inguinal canal

    In men: Spermatic cord (funiculus spermaticus) with the spermatic duct; deferential artery (branch of the inferior vesical artery) and testicular artery (from the aorta); venous pampiniform plexus; cremasteric artery and vein; genital branch of the genitofemoral nerve to the cremaster muscle; sympathetic nerve fibers; and lymphatic vessels. All invested by the internal spermatic fascia, cremasteric fascia, and external spermatic fascia. In women: Round ligament of uterus passing from the uterus through the deep inguinal ring into the inguinal canal and then on through the superficial inguinal canal to the labia majora; In addition, there are lymphatic vessels. The ilioinguinal nerve partly courses through the inguinal canal.

  • Types of hernias

    The deep inguinal ring is the weak spot for indirect hernias, while direct hernias originate in the middle inguinal fossa (medial to the deep inguinal ring and the inferior epigastric artery and vein).

    Indirect inguinal hernia

    • More common; men > women; congenital (patent processus vaginalis) or acquired (also via the deep inguinal ring in the lateral inguinal fossa, mostly in adults); hernia sac passes lateral to the epigastric vessels into the scrotum and labia majora respectively

    Direct inguinal hernia

    • Mostly acquired; in adults men > women; pouching of the peritoneum and transversalis fascia in the middle inguinal fossa (inguinal triangle, medial to the epigastric artery and vein); delimited medially by the transversus abdominis and inferiorly by the inguinal ligament; emerges most often through the superficial inguinal ring → scrotum/ labia majora.

    Femoral hernia

    Mostly acquired; in adults women > men; together with the femoral artery and vein through the femoral canal in the medial thigh (medial to the lacuna vasorum); femoral branch of the genitofemoral nerve; and lymphatic vessels.

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 24.09.2018

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  • Principle

    28-5

    Buttressing the posterior wall of the inguinal canal by laparoscopic insertion of a preperitoneal synthetic or biological mesh.

  • Accomplishing the pneumoperitoneum

    28-6

    Make a periumbilical skin incision of about 1 cm. Insert the Verres needle through this incision and accomplish pneumoperitoneum. In case of previous surgery, insert the trocar for the camera through a blunt minilaparotomy.

  • Trocar positions

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    After access to the abdominal cavity with the scissors, bluntly insert the trocar (10 mm) for the camera into the abdominal cavity and perform the initial inspection. At about the lateral level of the umbilicus insert a 5 mm trocar on the contralateral side of the hernia, while the ipsilateral side requires either a 5 mm or 10 mm trocar.

    Tip: The 30°/45° laparoscope with the camera should face anteriorly. This allows the surgeon to survey the posterior wall of the inguinal canal.

  • Reducing the contents of the hernia sac

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    Carefully free any adhesions with the scissors. If necessary, atraumatically clear any intestine and omentum from the hernia sac with graspers.

  • Incising and dissecting the peritoneum, exposing the anatomical landmarks

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    Transect the peritoneum in curved fashion superior to the hernia orifice from the medial umbilical fold to several centimeters lateral to the deep inguinal ring. Medial to the epigastric vessels, dissect between the bladder (Caution: Bladder injury!) and the posterior wall of the rectum up to the pectineal ligament (Cooper) and expose the symphysis. Now bluntly free the peritoneum caudad off the epigastric vessels, spermatic duct and the vessels of the spermatic cord.

    Tip: Start the incision well superior to the deep inguinal ring or well away from the hernia sac respectively.

  • Exposing and reducing the contents of the hernia sac, preparing the mesh support

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    Completely expose and reduce the hernia sac sparing the vessels (spermatic cord, epigastric, corona mortis).

    Identify any structures to be used for mesh support later on and all hernia orifices.

    Tip: Dissect the peritoneum off the vessels and spermatic duct over a sufficient distance since otherwise the mesh might flip up and over.

  • Mesh insertion

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    Trim the mesh and mark it. Then furl it up around the shaft of a grasper and insert it through the periumbilical trocar. With graspers place the mesh such that it covers all hernia orifices.

    In bilateral hernias insert and place the second mesh in identical fashion.

  • Mesh fixation

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    Avoiding any tension and with just a few staples, fixate the mesh to the pectineal ligament (Cooper) and the superior medial region of the anterior abdominal wall.

    As demonstrated in this example, another option would be to fixate the mesh with tissue sealant.

    When stapling beware of the following:

    Postoperative neuralgia may be avoided by inserting the staples neither inferior to the inguinal ligament nor lateral to the epigastric vessels. To rule out vascular injury (corona mortis), fixation at the pectineal ligament (Cooper) requires a clear view.

    Spare the following nerves which always course lateral to the epigastric vessels: lateral femoral cutaneous, ilioinguinal, iliohypogastric, genitofemoral (femoral and genital branches)!

    Depending on the toxicity of any tissue sealant used beware where the above nerves course.

    Note:
 For synthetic meshes synthetic tissue sealants may be used. The biomesh in the present example requires a fibrin tissue sealant.

  • Closing the peritoneal incision

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    Lower the pressure of the pneumoperitoneum to 6-8 mmHg and close the peritoneal incision with a running V-Loc suture 3/0.

    Remove the trocars under visual control and let the pneumoperitoneum escape. Suture the fascia at each incision > 5 mm from the outside, with percutaneous preplaced fascia sutures (suture catcher) if needed.

    Tip: When inserting a Redon drain down to the mesh, this is accomplished through the ipsilateral trocar incision and a small peritoneal incision; secure the drain with a skin suture.

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  • Intraoperative complications

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  • Postoperative complications

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  • mibeg-Institut Medizin

    PD Dr. med. Stefan Sauerland

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  • Literature summary

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