Multi-recurrent right inguinal hernia: advantages of the laparoscopic TAPP approach

Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective in recurrent hernia too. The objective of this video is to demonstrate how a multi-recurrent hernia in the right inguinal region can be treated laparoscopically using a TAPP approach. The patient had been operated upon using an anterior repair first. For the first recurrence, a laparoscopic posterior approach with placement of a posterior bilateral prosthesis via a TAPP approach was performed. The repair of the second recurrence was achieved with placement of a 4D-DOME prosthesis.

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Multi-recurrent right inguinal hernia: advantages of the laparoscopic TAPP approach

Authors

J Leroy, C Callari, J Marescaux

Abstract

Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective in recurrent hernia too. The objective of this video is to demonstrate how a multi-recurrent hernia in the right inguinal region can be treated laparoscopically using a TAPP approach. The patient had been operated upon using an anterior repair first. For the first recurrence, a laparoscopic posterior approach with placement of a posterior bilateral prosthesis via a TAPP approach was performed. The repair of the second recurrence was achieved with placement of a 4D-DOME prosthesis.

Classification

complex cases

Keywords

Multi-recurrent right inguinal hernia, advantages, laparoscopic TAPP approach

Media type

Surgical video

Duration

06'23''

Publication

2010-02

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E-publication

WeBSurg.com, Feb 2010;10(02).
URL: http://www.websurg.com/doi-vd01en2862.htm

Multi-recurrent right inguinal hernia: advantages of the laparoscopic TAPP approach

1. Introduction 00'09''

The objective of this video is to demonstrate how a multi-recurrent hernia in the right inguinal region can be treated laparoscopically using a TAPP approach.

2. Case presentation 00'19''

This patient had been operated upon using an anterior repair first. For the first recurrence, a laparoscopic posterior approach with placement of a posterior bilateral prosthesis via TAPP was performed. The repair of the second recurrence was achieved with placement of a 4D-DOME prosthesis.

3. Laparoscopic exploration 00'36''

The procedure for the third recurrence starts with the introduction of a port supra-umbilically to allow for exploration of the abdominal cavity. A prosthesis is then observed in the subperitoneal area and the 4D-DOME mesh is identified as being situated fairly high. On the CT-scan image, we had noticed that the hernia affected the right vesical horn. At this moment in the procedure, we decide to explore the subperitoneal space. We can observe that there is no recurrence phenomenon on the 4D-DOME mesh, and that it has been placed quite high compared to the recurrent hernia, which was apparently not at this level. We slide on the posterior aspect of the prosthesis that has been placed and we quickly notice that there is a dehiscence at the medial aspect of the prosthesis, where the vesical horn was situated, hence accounting for the urinary dysfunction that the patient was suffering from.

4. Retzius\' space dissection 01'50''

Gradually and after partial dissection of the Retzius’ space medially and slightly laterally, the hernial orifice containing the vesical horn and a pre-hernial lipoma is well identified. The dissection is continued by following the posterior aspect of the polypropylene prosthesis that was placed a couple of years ago. This prosthesis does obstruct the lateral side but not the medial side: it was either too small, or the prosthesis has moved laterally. Here we can observe the deep inguinal ring in which the hernia recurrence is located, just lateral to the posterior rectus sheath and just above the inguinal ligament, close to its pubic insertion.

5. Hernia sac reduction 03'03''

By applying repeated traction on the sac and using external taxis, the sac containing the vesical horn and a lipoma are finally completely reduced. Once the sac is completely reversed, view on the anterior part of the inguinal region is achieved. Freeing of the sac is further pursued. Then the Retzius’ space is opened on the posterior aspect of the pubis in order to sufficiently expose the symphysis pubis and obtain a complete view on the posterior part of the latter. Exploration of the inguinal region is further continued and we can observe that the defect is fairly small and that the prosthesis provides a perfect protection laterally.

6. Mesh insertion 04'21''

The first prosthesis is completed by the placement of a polyester mesh patch measuring around 8 by 8cm. This prosthesis is positioned on the posterior aspect of the pubic symphysis and will largely cover the midline medially.

7. Mesh fixation 04'46''

The prosthesis will be fixed to the Cooper’s ligament using absorbable staples of the AbsorbaTack® type. It is fixed to the entire wall using the same type of staples.

8. Mesh coverage 05'03''

The prosthesis now remains to be covered; as a reminder, this prosthesis completes the mesh that was placed previously in the preperitoneal space and that is still well positioned in order to close the deep inguinal ring. The peritoneum is freed in order to provide a large coverage. The peritoneum is fixed by ProTack® staples, which allows to easily cover the prosthesis. The coverage should be complete on the anterior part as well as on the posterior part to avoid the incarceration of a bowel loop in this prevesical space and in the preperitoneal space in contact to the prosthesis that has been placed.