Inguinal hernia repair, bilateral transabdominal preperitoneal hernioplasty (TAPP)

First, local anesthetic is applied supraumbilically and to the planned incision lines in the right and left mid-abdomen. Then, short supraumbilical incision and insertion of the Veress needle. The pneumoperitoneum can be established without problems with an insufflation pressure of 12 mm Hg.

Through the incision, the channel for the 10-mm trocar is first created with scissors and then inserted. Under diaphanoscopy and laparoscopic control with the camera, the two 5 mm working trocars are inserted in the right and left mid-abdomen respectively. The panoramic view shows clear medial hernia gaps in the lower abdomen on both sides.

Note 1: If no inguinal hernia is recognizable during inspection of the inguinal region, preparation should still be carried out, as the symptoms could be caused by the prolapse of a spermatic cord lipoma.

Note 2: After placing the trocars, the operating table is placed in the Trendelenburg position so that the intestines can be displaced to the upper abdomen, and tilted 20° toward the surgeon to enable better ergonomic working for him.

The incision of the peritoneum begins after external palpation in the area of the anterior superior iliac spine, runs in an arc 3-4 cm above the internal inguinal ring over the epigastric vessels and ends at the medial umbilical fold. The fold itself should not be severed.

Note: Asymptomatic adhesions in the lower abdomen do not need to be released, as the actual hernia repair is performed preperitoneally.

Medial to the epigastric vessels, preparation is then carried out between the bladder (caution: bladder injury) and the posterior wall of the rectus to the dorsal side of the symphysis and the Cooper's ligament is displayed.

Now, a larger medial hernia sac is dissected step by step (fascial defect M2 according to EHS (European Hernia Society) classification).

Note: The direct hernia consists of a peritoneal hernia sac and the so-called pseudosac, which consists of more or less dilated transversalis fascia. In cases of more severely dilated transversalis fascia, it should be inverted and either fixed to Cooper's ligament or gathered to prevent a seroma. When gathering the transversalis fascia, especially when using a Roeder loop, attention must be paid to the course of the ductus deferens (caution: accidental ligation!).

Next, the so-called parietalization is performed, which means detaching the hernia sac and peritoneum from the spermatic cord structures and the transversalis fascia or iliac fascia, respectively, to create a sufficiently large mesh bed. The ductus deferens and testicular vessels (spermatic vessels) are carefully lysed, revealing a small lateral component (L1 according to EHS) of the hernia sac. Laterally, preparation is done up to about 4-5 cm below the iliopubic tract and medially up to about 2-3 cm below the pubic bone. No tissue strands should remain that could roll up the mesh during peritoneal closure and thus lead to a recurrence.

Note: In women, the round ligament can be divided to avoid larger peritoneal lesions.

Same procedure as on the opposite side with arcuate incision of the peritoneum from lateral to the medial umbilical fold. Then preparation of the preperitoneal space as on the right and establishing a connection to the opposite side.