The operative steps to perform TEP and TAPP repairs are similar and have been described elsewhere [2
]. A detailed description of both techniques is provided below.
The patient is placed supine with both arms tucked and general anesthesia induced. The monitor is placed at the foot of the bed. If bilateral inguinal hernias are present, the more symptomatic side is repaired first. After pneumoperitoneum is established and the trocars are inserted, the patient is placed in the steep Trendelenburg position.
Operative steps for transabdominal preperitoneal (TAPP) repair
Three trocars are used for a TAPP repair: one 11-mm subumbilical port and two 5-mm ports placed in the same transverse plane as the subumbilical port, approximately 5-7 cm away. The 5-mm ports are just cephalad and medial to the anterior superior iliac spines (Fig. ).
Port placement for TAPP and TEP hernia repair
A 10-mm, 30°-angle laparoscope should be used to inspect the groin anatomy. The inferior epigastric vessels, the spermatic vessels, and the vas deferens should be identified. These three structures form the so-called “Mercedes-Benz” sign (Figs. , ). The peritoneum is incised several centimeters above the myopectineal orifice, from the edge of the medial umbilical ligament laterally toward the anterior superior iliac spine. Working inferiorly, in a motion similar to opening a piece of pita bread, the surgeon should bluntly dissect the peritoneum off the transversus abdominus and transversalis fascia until the pubis, Cooper’s ligament, and iliopubic tract are seen.
Right groin anatomy. The intersection of these three structures forms the “Mercedes-Benz” sign. D direct hernia, F femoral hernia, I indirect hernia, Inf inferior epigastric vessels, Sper spermatic vessels, Vas vas deferens
Photograph of right-sided inguinal anatomy with small indirect hernia
An indirect hernia sac is usually found on the anterolateral side of the cord. When dissecting the sac, it is important to minimize trauma to the vas deferens and the spermatic vessels. If the sac is sufficiently small, it should be completely dissected free from the cord and returned to the peritoneal cavity. Occasionally, a large sac will be encountered, in which case it should be dissected and divided beyond the internal ring. The subsequent peritoneal defect should be closed with an endoloop suture, because the intestine can herniate into the preperitoneal space through the peritoneal defect and become obstructed. The distal end of the transected sac should be left open to avoid formation of a hydrocele. The vas deferens and spermatic vessels are isolated and dissected free from the surrounding tissues circumferentially, creating a window inferiorly, to allow for passage of the lower tail of the mesh.
For indirect hernias, we use a 12-cm × 16-cm flat mesh with rounded corners and slit medially so that the tails wrap around the cord structures (Fig. ). The slit in the mesh allows it to lie flat in the preperitoneal space and avoids indirect recurrence. The tails are fixed to Cooper’s ligament with two tacks, avoiding the accessory obturator vein which courses in the region. One additional tack is placed laterally above the iliopubic tract. When fixing the mesh laterally, it is important to feel the tip of the device on the outside of the abdomen with the opposite hand to ensure that fixation occurs above the iliopubic tract. This avoids injury to the lateral femoral cutaneous nerve. It is also important to completely dissect the preperitoneal space so that the edge of the mesh does not fold. The mesh should be placed with a slight overlap of the midline to ensure adequate coverage of the myopectineal orifice. Finally, the peritoneal flap is placed back in its original position to cover the mesh. We use closely spaced tacks so that intestines cannot herniate through the peritoneum into the preperitoneal space.
Mesh repair of right-sided indirect hernia
Direct hernia sacs are reduced. When the peritoneum of a direct hernia sac is being reduced, a “pseudosac” may be present, which is actually adherent transversalis fascia that invaginates into the preperitoneal space during the dissection. This layer must be separated from the true hernia sac in order for the peritoneum to be released back into the peritoneal cavity. Once the pseudosac is freed, it will typically retract anteriorly into the direct hernia defect. For direct hernias, we use a preformed, contoured mesh (e.g., Bard 3D Max Mesh or Covidien Parietex Mesh) and anchor it with two tacks to Cooper’s ligament and with one tack laterally above the iliopubic tract (Fig. ). Again, peritoneum is replaced over the mesh and anchored with tacks.
Mesh repair of right-sided direct hernia
Operative steps for totally extraperitoneal (TEP) repair
Port placement for a TEP repair is similar to that for a TAPP repair, except all ports are placed in the preperitoneal space. The first 11-mm port is placed using an open technique. A subumbilical transverse skin incision is made and then advanced slightly off the midline, in front of the anterior rectus sheath. If the fascial incision is placed in the midline, it will enter the peritoneal cavity. The anterior sheath is opened transversely and the rectus muscle is swept laterally and retracted anteriorly. The posterior rectus sheath is seen and left intact. The 11-mm balloon-tip port is then inserted bluntly into the preperitoneal space and inflated. A 10-mm, 30°-angle laparoscope is inserted and used to bluntly dissect the areolar tissue in the preperitoneal space, using a gentle sweeping motion. The preperitoneal space is dissected laterally to the anterior superior iliac spine in order to place the 5-mm ports. Alternatively, a balloon dissector can be used to bluntly dissect out the preperitoneal space.
After the two 5-mm ports are placed, the inferior epigastric vessels, the pubic bone, and Cooper’s ligament are identified. This dissection should be done under direct vision to avoid injury to the small veins that overlie the pubic bone and the bladder. As Cooper’s ligament is exposed, a direct hernia, if present, will generally be reduced and a pseudosac may be found. Indirect hernia sacs are managed the same as for TAPP repairs. Cord lipomas are usually found laterally along the spermatic vessels and should be reduced.
Mesh strategy is the same as for a TAPP procedure. For direct hernias, we use a preformed, contoured mesh. The contoured surface of the mesh makes it easy to manipulate and it tends not to move within the preperitoneal space. For an indirect hernia, we use a large (16 cm × 12 cm) piece of flat mesh that is slit medially, passing the lower tail under the spermatic cord structures. The two tails are then overlapped and fixed to Cooper’s ligament medially.
Some open repairs, such as the Kugel mesh repair, plug repairs, and the Prolene Hernia System repair, place mesh in the preperitoneal space. This scars the peritoneum to the mesh and increases the difficulty of laparoscopic repair for recurrent hernia. Attempts to remove the prior mesh endanger cord structures, the bladder, and the iliac vessels. If the previously placed mesh is flat, we leave it in place and place new mesh on top of the old. If it protrudes, the protruding segment should be trimmed with electrocautery or shears. If a Kugel mesh is present, the ring should be inspected and, if fractured, it should be removed to avoid future complications. Access to the scarred preperitoneal space via TEP repair is difficult; a TAPP approach is safer when there is posterior mesh. Figure illustrates TAPP repair of a recurrent inguinal hernia with posterior mesh present from the first repair.
Fig. 6 TAPP repair of recurrent inguinal hernia in the presence of posterior mesh from a failed open repair. a A left-sided direct hernia is seen just medial to posterior mesh from the Prolene Hernia System, which is adherent to sigmoid colon. b Completed dissection. (more ...)