Transabdominal Preperitoneal (TAPP) Hernia Repair

Overview of the Procedure

Technique: A laparoscopic method used for inguinal hernia repair.
Process: Involves small incisions for inserting ports, surgical instruments, and a telescope for internal visualization.
Hernia Management: Repositions the herniated part of the abdomen and uses synthetic mesh to reinforce the weakened area.

Advantages

Better Anatomical View: Offers improved visualization of inguinal anatomy.
Shorter Incision: Compared to other hernia repair methods.
Detection of Contralateral Hernias: Can identify and treat asymptomatic hernias on the opposite side during the procedure.

Use of Mesh

Mesh Type: Commonly uses synthetic materials like Prolene mesh.
Concept: Based on the tension-free repair principle, enhancing the effectiveness of hernia repairs.

Surgical Steps

Diagnostic Laparoscopy: Initial step to assess the internal area.
Peritoneal Incision: Followed by creating a peritoneal flap through blunt dissection.
Hernia Sac Reduction: The hernia sac is carefully reduced.
Mesh Placement: A mesh is positioned to cover the defect.
Closure: The peritoneal flap is closed post mesh placement.

Safety and Complications

Safety Profile: Generally safe with a low incidence of postoperative complications.
Recurrence Risk: Possibility of hernia recurrence many years later, potentially needing another surgery.
Technical Difficulty: More complex than open repair with a steeper learning curve for surgeons.

Postoperative Care

Activity Restriction: Advised to avoid sports or strenuous activities for three weeks.
Recovery and Exercise: Regular exercise recommended for a swift return to normal activities.
Full Recovery Expected: Most patients can resume normal activities post-recovery.

Alternatives to Surgery

Non-Surgical Options: Using a truss (support belt) or no intervention.
Limitation of Alternatives: Hernias typically do not improve without surgical intervention.

Conclusion

Role in Treatment: TAPP hernia repair is an effective and modern technique, particularly suitable for patients requiring minimally invasive surgery, with the caveat of requiring skilled surgical expertise.

ANATOMICAL LANDMARKS

Pubic Symphysis: The pubic symphysis is the midline bony junction between the two pubic bones at the anterior floor of the pelvis. It serves as a medial landmark for dissection and mesh placement.
Inferior Epigastric Vessels: The inferior epigastric vessels, branches of the external iliac artery and vein, run along the medial edge of the rectus abdominis muscle. They are important structures to avoid during dissection and mesh placement.
Medial Umbilical Fold: The medial umbilical fold is a peritoneal reflection that contains the obliterated umbilical artery. It marks the medial boundary of Hesselbach’s triangle, a triangular area in the anterior abdominal wall where indirect inguinal hernias commonly occur.
Vas Deferens or Round Ligament: In males, the vas deferens passes through the inguinal canal and is a key landmark for indirect hernia detection. In females, the round ligament of the uterus, a homologue of the vas deferens, passes through the canal.
Anterior Superior Iliac Spine (ASIS): The anterior superior iliac spine is a bony prominence on the iliac bone, located just lateral to the pubic symphysis. It serves as an external landmark for trocar placement.
Cooper’s Ligament: Cooper’s ligament is a strong fibrous band that extends from the pubic tubercle to the pectineal line, forming the posterior border of Hesselbach’s triangle. It is a crucial landmark for identification of indirect hernias.
Corona Mortis: The corona mortis, also known as the ligament of Cooper, is an anastomotic vessel that connects the inferior epigastric vessels to the obturator vessels. It is located approximately 5 cm lateral to the pubic symphysis and should be identified to avoid injury.
Triangle of Pain: The triangle of pain is an area between the inferior epigastric vessels, the deep inguinal ring, and the iliopubic tract. It is a site where chronic pain can arise due to inguinal hernias or other conditions.
Dangerous Triangle (Triangle of Doom): The dangerous triangle is a small triangular area in the anterior abdominal wall, formed by the inferior epigastric vessels, the inguinal ligament, and the iliopubic tract. It is a potential site for incarcerated hernias and should be carefully evaluated.
Space of Retzius: The space of Retzius is a potential space in the anterior abdominal wall, located between the transversalis fascia and the peritoneum. It is a common dissection plane during TAPP hernia repair.

Corona Mortis: The corona mortis, also known as the ligament of Cooper, is an anastomotic vessel that connects the inferior epigastric vessels to the obturator vessels. It is located approximately 5 cm lateral to the pubic symphysis and should be identified to avoid injury.

Detailed Steps of the Transabdominal Preperitoneal (TAPP) Hernia Repair Procedure

1. Entering the Intra-abdominal Cavity

Incision and Access: An infraumbilical incision is used to access the peritoneal cavity.
Trocar Placement: A 10-12 mm trocar is placed for entry.

2. Creating the Peritoneal Flap

Adhesiolysis and Dissection: Adhesiolysis is performed followed by blunt dissection starting approximately 5 cm from the edges of the hernia defect.
Flap Creation: The peritoneal flap is created in a superior-to-inferior fashion.

3. Identifying the Anatomical Landmarks

Peritoneal Cut: Continues horizontally medially to the lateral umbilical ligament, then vertically along the ligament.
Hernia Visualization: The hernia is visualized, with a sharp incision made in the peritoneum 3-4 cm superiorly from the medial umbilical ligament.

4. Dissecting the Hernia Sac

Hernia Sac Dissection: This step can be challenging, especially in cases of large scrotal hernia, previous lower abdominal surgery, or recurrent hernia.

5. Deploying and Anchoring the Mesh

Mesh Placement: The mesh is deployed to cover the hernia defect.
Fixation: Mesh fixation is crucial to prevent migration.

6. Closing the Peritoneum

Re-approximation of Peritoneum: Accomplished using a running suture.
Original Technique: Involves using staples for mesh fixation and peritoneum closure.

7. Taking out Sutures & Port Closure

Port Removal: Ports are removed under direct visualization.
Fascial Closure: The fascial defect at the umbilicus is closed, also under direct visualization.

Importance of Surgical Expertise

Proficiency Requirement: TAPP hernia repair demands a high level of anatomical knowledge and surgical skill.
Success Factors: The success of the procedure hinges on meticulous execution of each step and effective management of potential complications.

Complications of Transabdominal Preperitoneal (TAPP) Hernia Repair

General Surgical Complications

Bleeding:
- Risk of bleeding during any surgical procedure.
Allergic Reactions:
- Potential allergies to equipment, materials, or medication.
Infection:
- Risk of infection at the surgical site.
Blood Clots:
- Possibility of clots in the leg (deep vein thrombosis) or lung (pulmonary embolism).
Chest Infection:
- Risk of developing a postoperative chest infection.

General Complications of Laparoscopic Surgery

Damage to Internal Structures:
- Risk of injury to the bowel, bladder, or blood vessels.
Surgical Emphysema:
- Presence of air in tissue layers.
Gas Embolism:
- Blockage of a blood vessel by a gas bubble.

Specific Postoperative Complications

Development of New Hernia:
- Possibility of new hernia formation post-surgery.
Hematomas and Scrotal Emphysema:
- Accumulation of blood (hematomas) and air (scrotal emphysema).
Urinary Retention:
- Difficulty in passing urine post-surgery.
Chronic Pain:
- Persistent pain as a significant postoperative issue.
Neuralgias (Nerve Pain):
- Incidence ranging from 0.5 to 4.6 percent.
Vascular Injury:
- Common during hernia repair, sometimes necessitating conversion to open surgery.
Testicular Complications:
- Pain, orchitis, epididymitis, and swelling due to seromas or hematomas.
Intestinal Obstruction:
- A rare but possible complication.

Decrease in Complication Rates Over Time

Experience Factor: Incidence of complications like neuralgias and vascular injuries may decrease as surgeons gain more experience with TAPP.

Comparison with Open Hernia Repair

Reduced Pain and Fewer Complications: Reportedly lower incidence of pain and complications compared to open hernia repair.
Shorter Hospital Stay and Disability Period: Benefits of TAPP include reduced hospital stay and a shorter duration of disability.

Consequences of TAPP Surgery

Pain:
- Postoperative pain is a common consequence.
Scarring:
- Potential for unsightly scarring at the incision sites.

Conclusion

Despite the potential complications, TAPP hernia repair is a preferred choice for many due to its minimally invasive nature, reduced pain, and quicker recovery compared to traditional open repair techniques. However, the risk of complications underscores the importance of skilled surgical execution and thorough patient monitoring during the postoperative period.