CHAPTER 112: REPAIR OF INGUINAL HERNIA, LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL (TAPP)

INDICATIONS

The indications for inguinal hernia repair have been described in the preceding chapters. The techniques that will be described include the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). Laparoscopic repair may be applied to indirect, direct, or femoral hernias. Laparoscopic inguinal herniorrhaphy is contraindicated in the presence of intraperitoneal infection, irreversible coagulopathy, and in patients who are poor risks for general anesthesia. Relative contraindications include large sliding hernias that contain colon, long-standing irreducible scrotal hernias, ascites, and previous suprapubic surgery. For TEP repairs, specific relative contraindications include incarceration and bowel ischemia. A thorough knowledge of the anatomy of the inguinal region is essential when it is approached posteriorly using a laparoscope. The view of this area as seen from the intraperitoneal perspective in the TAPP repair, as well as the one from the preperitoneal perspective in TEP, is shown on the preceding Chapter 111, entitled Laparoscopic Anatomy of the Inguinal Region. In addition, proficiency with laparoscopic skills or mentored experience with this type of hernia repair is strongly recommended.

TRANSABDOMINAL PREPERITONEAL (TAPP)

PREOPERATIVE PREPARATION

The patient must be a suitable candidate for general anesthesia. Anticoagulation, aspirin, and antiplatelet drugs such as Clopidogrel Bisulfate (Plavix) must be discontinued in advance of the procedure in order to avoid postoperative hematoma formation. Preoperative antibiotics should be administered intravenously within one hour of the incision.

EQUIPMENT AND SUPPLIES

All laparoscopic repairs use some form of prosthetic material. These include synthetic mesh created from polypropylene (Marlex or Prolene), Dacron (Mersilene), or polyester (Parietex). Expanded polytetrafluoroethylene (e-PTFE) (Gortex) is supplied as an extruded sheet. Mesh is generally preferred to e-PTFE because the structure allows fibrous in growth and hence greater fixation to the surrounding tissues. E-PTFE, composite mesh, or biologic materials are preferred in situations in which the prosthetic would be in touch with the intestine or other intra-abdominal organs, as it promotes less of a fibrous response and lessens adhesions to these structures. In this regard, e-PTFE has been modified to have polypropylene on one side. This so-called “dual mesh” might be useful in cases in which the mesh cannot be completely covered by peritoneum.

Fixation of the mesh is necessary to prevent migration and the tendency for the mesh to shrink overtime. There are a variety of tacking devices that may be used including helical coils, shaped like a key ring, and anchors. They may be absorbable or nonabsorbable metal. Most are delivered with 5-mm disposable instruments.

ANESTHESIA

General endotracheal anesthesia is required.

POSITION

The patient is placed in the supine position, and the arms are tucked. The operating room setup and port placements are shown in figure 1.

OPERATIVE PREPARATION

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