Laparoscopic Repair of the Right Inguinal Hernia (TAPP REPAIR)
Author(s): Chalkoo M, Masoodi I
Vol. 5, No. 3 (2008-07 - 2008-08)
ISSN: 0973-516X
Chalkoo M, Masoodi I
Dr Mushtaq Chalkoo, MS, FAMS, Consultant Laparoscopic and Minimal Access Surgery,Government Medical College Srinagar,and SMHS Hospital, Srinagar. Dr Ibrahim Masoodi, MD, DM, Gastroenterologist, Directorate of Health Services, Kashmir.
Correspondence: Dr Mushtaq Chalkoo, E.mail: mushtaq_chalkoo(at)rediffmail.com; Cell: 9419032292
Abstract
We present the first case of the right inguinal hernia repair being performed at a rural sub-district hospital by the laparoscopic technique. The patient was a 42 year old male farmer, diagnosed as having right inguinal hernia. We performed laparoscopic transabdominal preperitoneal hernioplasty. The patient had a successful surgery and was discharged the next day.
Keyword: laparoscopy; inguinal hernia, rural hospital
Introduction
The success of laparoscopic cholecystectomy has resulted in an intensified effort to apply the concept of minimal access surgery to other operative procedures like inguinal hernia. The laparoscopic hernia surgery initially was a controversial topic but now, with a decade of experience in lap hernia surgery, the dust seems to be settling down towards accepting the superiority of the laparoscopic repair over the conventional repairs. This is due mainly to an increased understanding of the endoscopic inguinal anatomy, effacement of the initial procedures like plug and patch technique, refinement of the new technique, and introduction of the preperitoneal placement of mesh. The laparoscopic technique has many advantages over the open technique for hernia repair. Firstly there is reduced postoperative pain and short recovery period. Secondly the entire myopectineal orifice can be inspected allowing for any unexpected hernias thereby reducing the chances of recurrence. Thirdly the laparoscopic hernioplasty avoids the previous operative scar site in patients with recurrent hernias. The disadvantages of the laparoscopic repair are the need for general anaesthesia, the breach of the peritoneum in the TAPP repair and the cost of the procedure. To start with, TAPP may be a better approach to gain adequate working knowledge and understanding of the inguinal anatomy. After adequate experience with TAPP technique one can proceed with TEP repairs.
Case Report:
TAPP TECHNIQUE FOR RIGHT INGUINAL HERNIA
STEP 1: The patient was positioned on the operating table with a slight shift towards right lateral position. The abdomen was washed with betadine. The patient was catheterized. Pneomoperitoneum was created in the usual fashion (sub-umbilical position).The first trocar (10mm) was introduced through the umbilical port. The intra-abdominal cavity was visualized with the 0 degree telescope and the findings were confirmed. Two additional ports (5mm each) were made under vision.
STEP-2: The repair was initiated. The laparoscope was pointed towards afflicted inguinal canal. The peritoneal defect and the hernia were identified. The peritoneal incision was made using the scissors. The incision was extended from the lateral aspect of the inguinal region to the lateral umbilical ligament. The incision was made as high as possible to maximize the exposure of the region.
STEP-3: With blunt dissection the Cooper’s ligament was exposed as well as the inferior epigastric vessels and the spermatic cord. The iliac vessels were not dissected but their position was identified.
STEP-4: The indirect hernia sac was dissected off from the spermatic cord, care being taken not to dissect inferior to the Cooper’s ligament as the iliac vessels enter the femoral canal. Care was also taken not to injure the vas deferens.
FIG-1 The view with 0° telescope. The internal ring, the direct hernia defect, the medial umbilical ligament (inferior epigastric artery) and the lateral umbilical ligament seen.
FIG-2: The incision made in the peritoneum to lift the peritoneal flap.
FIG-3: The peritoneal flap lifted, the white glistening structure is cooper’s ligament.
FIG-4: The pseudo sac (transversalis fascia) separated from the sac.
FIG-5: Complete dissection the hernia reduced.
STEP-5: A 6٭6 inch mesh was rolled in like a cigarette and was inserted through the 10 mm port and deployed over the inguinal region.
We did not fix the mesh, however, we splayed it properly over the dissected inguinal region to cover the all the three openings.
STEP-6: The peritoneum was closed over the mesh taking care not o folds the mesh .We used 30
vicryl for closure. The trocars were removed under vision and the ports were closed.
FIG-7 Mesh being unrolled
FIG-8: The properly splayed mesh covering all the defects
Discussion
The two major controversies regarding the prosthesis in laparoscopic hernia repair are the fixation of the mesh and the avoidance of the splitting of the mesh. Recurrence through the area of the slit, due to loss of the integrity of the mesh, increased risk of injury to the testicular vessels and testicular atrophy, are the main disadvantages of slitting of the mesh. Injury to the iliac vessels may occur during dissection posterior to the cord structures in this region. It is dangerous to dissect with the electro-cautery. The slitting of the mesh is no longer recommended by many surgeons. Fixation of the prosthesis represents a major ongoing controversy. Fixation or anchoring of the mesh to multiple areas was the recommended procedure when these repairs were introduced. There was a multitude of reports of nerve injuries and vascular injuries due to indiscriminate use of fixation devices in all areas. The large increase in the abdominal pressure helps to keep the mesh in place between the layers of abdominal wall2.
FIG-9: The peritoneum being closed.
There is no significant movement of mesh which was studied postoperatively at 1, 7, 28 days and 3 months after laparoscopic hernia repair2,3. Various trials have shown that there is no difference in the recurrence rates of stapled versus non-stapled mesh repairs4. Other authors focus on the lack of fixation as major cause of recurrence5. Although the debate is on, currently the majority of surgeons agree that the fixation should be reduced to as minimum as possible.
Conclusion
TAPP repair for inguinal hernia is widely used because of its relative ease. Invasion into the peritoneal space for treatment of the defect in the abdominal wall is one of the major drawbacks of this technique. The peritoneal incision and its closure might increase the chances of postoperative adhesions and small bowel obstruction. Insufficient closure of this incision will lead to the formation of internal hernia with its complications. The size of the mesh which is kept inside is comparatively smaller than in that in the TEPP procedure. As documented in various studies, this smaller mesh might produce increased recurrence rates. Because of these concerns laparoscopic surgeons are switching to TEP repair. However, a surgeon who is interested in performing the laparoscopic hernia repair should begin with TAPP approach, as the inguinal anatomy is less complex and easy to learn in the initial period. With adequate number of cases, the surgeon will be more confident in performing the extra peritoneal approach. Still TAPP will remain an ideal approach for management of the difficult inguinal hernias such as incarcerated hernias, sliding hernias and other complex hernias
References
- Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13;545-54.
- Quilici PJ et al: Laparoscopic inguinal hernia repair; results in 131 cases. Am Surg 1993 Dec; 59(12):824-3.
- Toy KF et al; Toy-smooth laparoscopic hernioplasty. Del Med J, Jan 1992;4-11.
- Davis CJ,Arregui ME. Laparoscopic repair for groin hernias. Surg Clinic North Am 2003;83:1141-61.
- Felix EL et al;laparoscopic hernioplasty;TAPP vs TEPP. Surg Endosc 1995; 9;984-989.
Further Reading:
- Quilici PJ et al:laparoscopic inguinal repair;results in 509 cases.Am Surg oct;62(10);849-5
hernia 1996
- Felix EL. A unified approach to laparoscopic hernia repairs. Surg 2001;15:969-71.
recurrent Endosc
- Mc Gillicuddy JE; Prospective randomized comparison of the Shouldice and Lichtenstein hernia repair procedures. Arch Surg,1998;133-974978.
- RJ Rosengerger et al; The cutaneous nerves encountered during endoscopic repair of inguinal hernia. Surg Endosc, 2000; 14;731-735.
ISSN: 0973-516X
Chalkoo M, Masoodi I
Dr Mushtaq Chalkoo, MS, FAMS, Consultant Laparoscopic and Minimal Access Surgery,Government Medical College Srinagar,and SMHS Hospital, Srinagar. Dr Ibrahim Masoodi, MD, DM, Gastroenterologist, Directorate of Health Services, Kashmir.
Correspondence: Dr Mushtaq Chalkoo, E.mail: mushtaq_chalkoo(at)rediffmail.com; Cell: 9419032292
Abstract
We present the first case of the right inguinal hernia repair being performed at a rural sub-district hospital by the laparoscopic technique. The patient was a 42 year old male farmer, diagnosed as having right inguinal hernia. We performed laparoscopic transabdominal preperitoneal hernioplasty. The patient had a successful surgery and was discharged the next day.
Keyword: laparoscopy; inguinal hernia, rural hospital
Introduction
The success of laparoscopic cholecystectomy has resulted in an intensified effort to apply the concept of minimal access surgery to other operative procedures like inguinal hernia. The laparoscopic hernia surgery initially was a controversial topic but now, with a decade of experience in lap hernia surgery, the dust seems to be settling down towards accepting the superiority of the laparoscopic repair over the conventional repairs. This is due mainly to an increased understanding of the endoscopic inguinal anatomy, effacement of the initial procedures like plug and patch technique, refinement of the new technique, and introduction of the preperitoneal placement of mesh. The laparoscopic technique has many advantages over the open technique for hernia repair. Firstly there is reduced postoperative pain and short recovery period. Secondly the entire myopectineal orifice can be inspected allowing for any unexpected hernias thereby reducing the chances of recurrence. Thirdly the laparoscopic hernioplasty avoids the previous operative scar site in patients with recurrent hernias. The disadvantages of the laparoscopic repair are the need for general anaesthesia, the breach of the peritoneum in the TAPP repair and the cost of the procedure. To start with, TAPP may be a better approach to gain adequate working knowledge and understanding of the inguinal anatomy. After adequate experience with TAPP technique one can proceed with TEP repairs.
Case Report:
TAPP TECHNIQUE FOR RIGHT INGUINAL HERNIA
STEP 1: The patient was positioned on the operating table with a slight shift towards right lateral position. The abdomen was washed with betadine. The patient was catheterized. Pneomoperitoneum was created in the usual fashion (sub-umbilical position).The first trocar (10mm) was introduced through the umbilical port. The intra-abdominal cavity was visualized with the 0 degree telescope and the findings were confirmed. Two additional ports (5mm each) were made under vision.
STEP-2: The repair was initiated. The laparoscope was pointed towards afflicted inguinal canal. The peritoneal defect and the hernia were identified. The peritoneal incision was made using the scissors. The incision was extended from the lateral aspect of the inguinal region to the lateral umbilical ligament. The incision was made as high as possible to maximize the exposure of the region.
STEP-3: With blunt dissection the Cooper’s ligament was exposed as well as the inferior epigastric vessels and the spermatic cord. The iliac vessels were not dissected but their position was identified.
STEP-4: The indirect hernia sac was dissected off from the spermatic cord, care being taken not to dissect inferior to the Cooper’s ligament as the iliac vessels enter the femoral canal. Care was also taken not to injure the vas deferens.
FIG-1 The view with 0° telescope. The internal ring, the direct hernia defect, the medial umbilical ligament (inferior epigastric artery) and the lateral umbilical ligament seen.
FIG-2: The incision made in the peritoneum to lift the peritoneal flap.
FIG-3: The peritoneal flap lifted, the white glistening structure is cooper’s ligament.
FIG-4: The pseudo sac (transversalis fascia) separated from the sac.
FIG-5: Complete dissection the hernia reduced.
STEP-5: A 6٭6 inch mesh was rolled in like a cigarette and was inserted through the 10 mm port and deployed over the inguinal region.
We did not fix the mesh, however, we splayed it properly over the dissected inguinal region to cover the all the three openings.
STEP-6: The peritoneum was closed over the mesh taking care not o folds the mesh .We used 30 vicryl for closure. The trocars were removed under vision and the ports were closed.
FIG-7 Mesh being unrolled
FIG-8: The properly splayed mesh covering all the defects
Discussion
The two major controversies regarding the prosthesis in laparoscopic hernia repair are the fixation of the mesh and the avoidance of the splitting of the mesh. Recurrence through the area of the slit, due to loss of the integrity of the mesh, increased risk of injury to the testicular vessels and testicular atrophy, are the main disadvantages of slitting of the mesh. Injury to the iliac vessels may occur during dissection posterior to the cord structures in this region. It is dangerous to dissect with the electro-cautery. The slitting of the mesh is no longer recommended by many surgeons. Fixation of the prosthesis represents a major ongoing controversy. Fixation or anchoring of the mesh to multiple areas was the recommended procedure when these repairs were introduced. There was a multitude of reports of nerve injuries and vascular injuries due to indiscriminate use of fixation devices in all areas. The large increase in the abdominal pressure helps to keep the mesh in place between the layers of abdominal wall2.
FIG-9: The peritoneum being closed.
There is no significant movement of mesh which was studied postoperatively at 1, 7, 28 days and 3 months after laparoscopic hernia repair2,3. Various trials have shown that there is no difference in the recurrence rates of stapled versus non-stapled mesh repairs4. Other authors focus on the lack of fixation as major cause of recurrence5. Although the debate is on, currently the majority of surgeons agree that the fixation should be reduced to as minimum as possible.
Conclusion
TAPP repair for inguinal hernia is widely used because of its relative ease. Invasion into the peritoneal space for treatment of the defect in the abdominal wall is one of the major drawbacks of this technique. The peritoneal incision and its closure might increase the chances of postoperative adhesions and small bowel obstruction. Insufficient closure of this incision will lead to the formation of internal hernia with its complications. The size of the mesh which is kept inside is comparatively smaller than in that in the TEPP procedure. As documented in various studies, this smaller mesh might produce increased recurrence rates. Because of these concerns laparoscopic surgeons are switching to TEP repair. However, a surgeon who is interested in performing the laparoscopic hernia repair should begin with TAPP approach, as the inguinal anatomy is less complex and easy to learn in the initial period. With adequate number of cases, the surgeon will be more confident in performing the extra peritoneal approach. Still TAPP will remain an ideal approach for management of the difficult inguinal hernias such as incarcerated hernias, sliding hernias and other complex hernias
References
- Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13;545-54.
- Quilici PJ et al: Laparoscopic inguinal hernia repair; results in 131 cases. Am Surg 1993 Dec; 59(12):824-3.
- Toy KF et al; Toy-smooth laparoscopic hernioplasty. Del Med J, Jan 1992;4-11.
- Davis CJ,Arregui ME. Laparoscopic repair for groin hernias. Surg Clinic North Am 2003;83:1141-61.
- Felix EL et al;laparoscopic hernioplasty;TAPP vs TEPP. Surg Endosc 1995; 9;984-989.
Further Reading:
- Quilici PJ et al:laparoscopic inguinal repair;results in 509 cases.Am Surg oct;62(10);849-5 hernia 1996
- Felix EL. A unified approach to laparoscopic hernia repairs. Surg 2001;15:969-71. recurrent Endosc
- Mc Gillicuddy JE; Prospective randomized comparison of the Shouldice and Lichtenstein hernia repair procedures. Arch Surg,1998;133-974978.
- RJ Rosengerger et al; The cutaneous nerves encountered during endoscopic repair of inguinal hernia. Surg Endosc, 2000; 14;731-735.