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Laparoscopic Transabdominal preperitoneal repair
Overview
The repair of the recurrent hernia is a daunting task because of already weakened tissues and distorted anatomy. Open posterior preperitoneal approach gives results far superior to those of the anterior approach. Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is an evolving technique associated with advantages of a minimally invasive approach. The present work aimed at comparing these three approaches for repair of recurrent inguinal hernia regarding complications and early recurrence.
Operative Techniques
The open preperitoneal approach to the inguinal region was performed under general or regional anesthesia, as originally described by Nyhus. Through a lower abdominal transverse incision, the anterior rectus sheath was incised and the rectus muscle reflected medially. The preperitoneal space was cleaved with blunt dissection, exposing the myopectineal orifice. The cord was explored and the hernias were reduced. A 15 ×15 cm2 polypropylene mesh with a slit was inserted in the preperitoneal space and fixed with non-absorbable sutures to pubic tubercle and Cooper's ligament. The mesh was passed behind the cord and manipulated to lay flat against the posterior inguinal floor overlapping the entire myopectineal orifice.
The anterior tension-free repair, as defined by Lichtenstein et al., was performed using 6 × 11 cm2 polypropylene mesh. Large pore-sized (1.6 mm), monofilament heavy-weight polypropylene meshes were used (Prolene® ; Ethicon, Egypt). Really our patients were oriented to the type of repair and the other observers were unaware to operative techniques of the study groups.
The two 5 mm trocars are placed guided by the index finger to prevent their placement in the intra-peritoneal position. The Hasson cannula is then placed into the space under vision with the help of S-type retractors and the pre-peritoneal space is insufflated with CO2 to 10 mmHg.
The laparoscopic transabdominal preperitoneal repair (TAPP):
The hernia defect was inspected. The properitoneal space was dissected from lateral to medial at the level of the retroinguinal (Bogros') space,
with parietalization of the spermatic cord posteriorly and outwards. The dissection was continued medially toward the retropubic space, extending behind the symphysis pubis and iliopubic tract, exposing the pectineal ligament.
The peritoneum forming the hernia sac was pulled in, separating it from the cord structures. A 15 × 10 cm2 sheet of polypropylene mesh was placed so as to cover the Hesselbach's triangle,
the indirect space, and the femoral ring areas. The mesh was fixed using an endoscopic multifire hernia stapler (Ethicon, Johnson and Johnson), beginning at the pubic tubercle and proceeding laterally.
The peritoneum is tightly closed using 3/0 running vicryl suture. The trocars are removed under direct vision, and the peritoneum is deflated.
The fascia at the two 10/12 mm port site is closed using 2-0 Prolene sutures.
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