Easy tricks to start preperitoneal repair of inguinal hernia by Laparoscopy. From - Gateway Clinics, Coimbatore, India.

1. TAPP – Tips, Tricks & Technique
(TransAbdominal PrePeritoneal Repair of Inguinal Hernia)
Dr. Piyush Patwa
Consultant Laparoscopic Surgeon, Gateway Clinics, India
Chief – Dr. K. Sendhilkumar

2. Definition
• Transabdominal preperitoneal technique:
A laparoscopic repair procedure wherein the
surgeon enters the peritoneal cavity, incises
the peritoneum, enters the preperitoneal
space, and places the mesh over the hernia;
the peritoneum is then sutured or tacked.

3. Lets do it step by step
• STEP 1: Entering the Intra-abdominal Cavity
• STEP 2: Creating the Peritoneal Flap
• STEP 3: Identifying the Anatomical Landmarks
• STEP 4: Dissecting the Hernia Sac
• STEP 5: Deploying and Anchoring the Mesh
• STEP 6: Closing the Peritoneum
• STEP 7: Taking out Sutures & Port Closure

4. Preoperative Care
• It is recommended that the patient empty
his/her bladder before the operation.
• Restrictive per- and postoperative intravenous
fluid administration reduces the risk of
postoperative urinary retention.
• If you expect technical difficulties (e.g., after
prostatic surgery, Scrotal hernia) or an
extended operating time, consider using a
urinary catheter during the intervention.

5. Preoperative Care
• The patient with unilateral groin hernia should
be asked to give his/her consent to allow
simultaneous repair if a contralateral occult
hernia is found and he/she wishes it.

6. Table – Patient Position
• Supine position
• head-down position during the operation and
slightly (approximately 15°) turned toward the
surgeon.
• The operating surgeon & the camera assistant
stay on opposite sides of the hernia.

7. TAPP STEP 1: Entering the Intra-abdominal Cavity
Trocar placement
• Establishing the carbon dioxide
pneumoperitoneum using the Veress needle.
• The 10 mm optical trocar – supraumbilical
• Under laparoscopic view - Two 5 mm
operating trocars on the midclavicular line 2
cm below the level of the horizontal line from
the umbilicus.

8. Tips
• The intra-abdominal cavity is visualized with
the Telescope and intra-abdominal findings
are reported [intra-abdominal pathology and
inguinal hernia defects and sacs].
• If an asymptomatic hernia sac is identified on
the contralateral side, our protocol mandates
its repair, even though at this time we are unsure of its
exact clinical significance.

9. Preperitoneal dissection
• The aim of this step is to ensure the best positioning of the mesh. In this
way several anatomic landmarks have to be identifying, as well as a
complete dissection of the hernia’s sac.
• The anatomic landmarks are:
 Epigastric vessels,
 Urinary bladder,
 Pubis
 Cooper’s ligament,
 Gimbernat’s ligament
 Medial part of ilio-pubic tract
 External iliac vessels
 Corona mortis
 Vas deferens in males and Round ligament in females
 Spermatic vessels,
 Internal inguinal ring

10. STEP 2: Creating the Peritoneal Flap

11. Incision of the peritoneum
The peritoneal incision starts 2 cm above the iliac spine/ 5cm
above defect using the monopolar scissors/hook.

12. Incision of the peritoneum – cont ..

13. Entering the Lateral Inguinal Space

14. STEP 3: Identifying the Anatomical Landmarks
• Exploration and anatomical landmarks
• The aim of the laparoscopic exploration is to
identify the anatomical landmarks
• Site and type of hernia. In this way, the
Trendelenburg tilt should be increased to 30-
45º.
The two dangerous “triangles”,
• 1) vascular triangle- Triangle of Doom and
• 2) Pain triangle has to be well identified .
• And Corona Mortis

15. Death, Destruction,or some other terrible fate

16. “Triangle of doom" landmark does protect the
surgeon from damaging the external iliac
vessels, a portion of these vessels lie outside of
this area.

19. “Triangle of Pain"
• The so-called "triangle of pain" & "triangle of doom“ are
misnomers.
• Not a triangle, has only two boundaries.
• The "triangle of pain" is an inverted "V" shaped area with its
apex at the internal (deep) inguinal ring. It is bound anteriorly
by the iliopubic tract / inguinal ligament and by the Gonadal
vessels posteromedially.

20. Triangle of Pain – Cont …
• Don’t place staples or sutures to anchor the
mesh – as several nerves which usually cannot
be seen as they run just deep to the
Endoabdominopelvic fascia.
• TIP – Don’t open this fascia to see nerves !
• These nerves can suffer damage with
electrocautery or entrapment - cause pain
(hence the name of the area).

22. CORONA MORTIS
• Latin - [corona] meaning "crown' &
[mortis] meaning "death‘
the "crown or circle of death".
The corona mortis refers to an anatomical variation, a
vascular anastomosis between the obturator & the
external iliac vascular systems that passes over
Cooper's pectineal ligament and posterior to the
lacunar (Gimbernat's) ligament.

23. • In some cases, the corona mortis is the actual
obturator artery- arises from the inferior
epigastric artery instead of the internal iliac
artery.
• It can also arise from the external iliac artery.
In both cases, it has been called an "
aberrant obturator artery".

25. • The preperitoneal dissection ends when the
anatomic landmarks previous described are
well exposed and the two dangerous triangles
(vascular and pain triangle) can be identified.

26. STEP 4: Dissecting the Hernia Sac
• The indirect inguinal hernia sac should be dissected carefully
from the Spermatic Cord.
• It is essential to expose and know at all times where the
spermatic cord is located. Direct hernia sacs are easily
dissected.
• Particular care should be taken not to dissect lateral and
inferior to Cooper's ligament, as the Iliac Artery and Vein will
enter the femoral canal at this site.

27. The hernia sac dissection is performed using traction contra-
traction maneuvers and fine coagulation. To avoid the injuries of
the ductus deferens and spermatic vessels the sac dissection
always starts anteriorly.

28. Pseudosac dissection in a Direct Hernia

29. • A large indirect sac may be ligated proximally
and divided distally without the risk of a
higher postoperative pain & recurrence rate,
but with an increased postoperative seroma
rate *
* Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal
hernia (International Endohernia Society) Surg Endosc (2015) 29:289–321

30. • When performing inguinal hernia repair in
women, extra effort should be undertaken to
reveal and treat occult synchronous femoral
hernia

31. STEP 5: Deploying and Anchoring the Mesh
• A large (12x15 cm) polypropylene mesh.
• The mesh is inserted from the Camera trocar.
Then, the mesh is placed in the appropriate
position and fixed by 1 Prolene sutures (or
tacking staples ,glue in some centres). The first
suture is at the level of pubis
• The mesh is fixed on the upper and internal edge
• The mesh shouldn’t be sutured/stapled at the
level of dangerous triangles and epigastric vessels

32. The 12*15 cm Mesh is rolled like a cigarette & inserted

33. The Mesh should cover Myopectineal orifice.
When the mesh is smoothed out, it overlaps the pubic bone & crosses midline
TIP – wrinkles or folds should not be seen

34. The Mesh is secured to Cooper's Ligament,

35. •The mesh is fixed on the upper and internal edge

36. STEP 6 - The peritoneal closure
• A thorough closure of peritoneal incision or
bigger peritoneal tears should be achieved.
• The peritoneum is closed by a running suture
using a 2-0 vicryl.
• Look - Mesh is not exposed now to abdominal
organs.

37. The peritoneum is closed by a running 2-0 vicryl suture.
TIP – Far to Near

38. • To improve postoperative pain control, trocar
wounds can be infiltrated by local anaesthetic
drug.