SINGLE MESH TECHNIQUE FOR BILATERAL

INGUINAL HERNIA TAPP REPAIR

D R . E N A S A L - A L AW I
Consultant General and Laparoscopic surgeon
MB BCH BAO NUI,FRCSI

PRESNTED BY

DR.AHMED ABDELKADER
MBBCH,MRCS

INTRODUCTION
Laparoscopic inguinal hernia repair originated in the early
1990s as laparoscopy gained a foothold in general surgery.
Inguinal hernias account for 75% of all abdominal wall
hernias, and with a lifetime risk of 27% in men and 3% in
women. .
Although open, mesh-based, tension-free repair remains the
criterion standard, laparoscopic herniorrhaphy, in the hands
of adequately trained surgeons, produces excellent results
comparable to those of open repair.
The learning curve for laparoscopic hernia repair is
prolonged with most estimates ranging between 50 and 75
procedures. However, when performed by an experienced
surgeon (>75 repairs), hernia recurrence is low

Advantages Vs Disadvantages
A number of studies have shown laparoscopic
Laparoscopic
repair
has to
some
disadvantages
repair
of inguinal
hernias
have
advantages as well,
including
the following:
over
conventional
repair, including the
following
Reduced
Increased
cost :postoperative
Although the pain
actual hospital costs
of
Diminished
requirement
for higher
narcotics
laparoscopic
repairs are
than those of
open
Earlier
return to
repairs,
thework
increased cost may be offset by
the societal benefits of earlier return to full
activities. Lengthier operation
Steeper learning curve
Higher recurrence and complication rates early in a
surgeons experience

Indications
The
definitive treatment
all hernias,
Re-recurrence
rates mayofdecline
to 5% or
regardless
their origin repair,compared
or type, is surgical
lower with of
laparoscopic
The reduced pain after laparoscopic inguinal
repair
.
with rates
as high as 20% for anterior
hernia repair as compared with conventional
Some
repair.reports have listed specific indications
repair makes laparoscopy the
anterior
for
laparoscopy
over open repair,
studies
from experienced
herniaincluding
surgeons
approach of choice for bilateral hernias.
recurrent
hernias,
bilateral rates
hernias,
have reported
recurrence
for and the
need
for earlier
return
to range
full activities.
laparoscopic
repair
that
from 1% to
3%.

Contraindications
Factors that may contraindicate a laparoscopic
approach, and thus favor an open approach
Absolute contraindications:
Relative
contraindications:

Inability
to tolerate
anesthesia:
there
Prior
pelvic
surgery: general
surgeons
should be though
aware that
are reports
anesthesia
being
used for this
TAPP
repairsofinspinal
patients
who have
undergone
procedure. coagulopathy
(because
bleeding
the
prostatectomy
are more difficult
and
carry a in
higher
preperitoneal space can be difficult to assess and
morbidity.
control postoperatively)
Incarcerated
inguinal hernia
Large
Activescrotal
infection:
that limit the use of prosthetic
hernia
Ascites
meshes.


TECHNIQUE TYPES

The term laparoscopic inguinal herniorrhaphy can refer

to any of the following 3 techniques:
Totally extraperitoneal (TEP) repair
Transabdominal preperitoneal (TAPP) repair
Intraperitoneal onlay mesh (IPOM) repair [16, 17, 18, 19]
The IPOM repair has largely fallen from favor, and
currently, the most commonly performed laparoscopic
techniques are the TEP and TAPP repairs. [14, 15, 8]

TAPP VS TEPP
A Cochrane database
meta-analysis
comparing TEP with
TAPP found no
significant difference
in recurrence rates
but did find that TAPP
was associated with a
higher risk of intraabdominal injury. The
authors concluded
that further
randomized
controlled trials are
needed for definitive
comparison of these
2 techniques.

The disadvantage of the

TAPP procedure is that it
requires entry into the
peritoneal cavity, which can
result in an injury to
adjacent abdominal organs,
adhesions resulting in
intestinal obstruction, or
bowel herniation. One
advantage of TAPP is that it
can be easily be performed
TEP advantages
in patientsover
withTAPP,
prior lower
including the
following:
midline
surgery
Less risk of intraperitoneal
injury
Fewer intra-abdominal
adhesions

Visceral Injuries
One patient early in the series,
Meralgia Paraesthetica
after a number of previous
The incidence of this
abdominal operations and despite
condition has now
being warned of the increased
disappeared since we
risks, requested a laparoscopic
stopped stapling the ileorepair. A hole was made in the
pubic tract or posterior to it.
small bowel which necessitated
This complication has been
conversion. Now, in patients who
recognised in the literature
have previously undergone
from an early stage and
abdominal surgery, an optical
guidance given on its
trochar (Visiport
Auto-Suture) is
avoidance.6
used for initial entry into the
abdomen.

Recurrence
Bleeding
damage
to subcutaneous
Since changing
to 15vessels
x10 or branches
of the inferior epigastric artery during lateral
cm
mesh in early 1996 no
port insertion.: transilluminate the abdominal
recurrences
have been
wall with the telescope
light prior to port
insertion.
recorded although the
Scrotal
Sinceisthe technique was
followbruising:
up period
changed and sacs were circumcised in relation
obviously
shorter
to the internal
ring with the distal sac left in
Recurrence
rates after
situ,
this complication
has diminished.
seroma
in the sac
remnants:
Seromas
TAPP repair
usually
range
represent the most common postoperative
from
1% to 6%;
complication. These usually resolve
specialized
spontaneously centers
and rarely warrant further
intervention
(eg,
aspiration).
performing
large
numbers
of repairs cite rates of less
than 1%.

COMPLICCATI
ONS

Small Bowel Obstruction

Ensure
thatHernias
extensive peritoneal flaps are
Port Site
created
so that
can
be
the incidence
ofthe
thisperitoneum
complication
has
reconstituted
atwe
thehave
end of
diminished and
yetthe
to procedure
see a
by
staples
or sutures and that they are
further
hernia.

Urinary Retention
One of the commonest reasons
for delayed discharge in day case
patients: mobilize patients early
after operation and encourage

TECHNIQUE
Full
GA body suit
peritoneal
Oral
Antibiotics
supine
reflection
position for
Admission on same day of surgery
5
daysumbilical
postand
op
5mm
Dissection
Fasting from mid night
Simple
analgesia
optical trocar
identification
of of
One fleet enema on admission
paracetamol
and
10mm right trocar
anatomy
Void before shifting to OR
fortrocar
5 days.
5 brufen
20x30
mm left
cm
mesh
Intravenous ceftrioxone 1g on induction
Driving
5 days
5mm 30after
shaped
todegree
standard
Intravenous Gentamicin 80mg on insertion of mesh
Return
to work
telescope
measurements
after
Pneumoperitonium
Mesh
fixation to
1-2
weeks
12
ASIS
mmhg
BILATERALLY
Clinic
followposition
up - 1
HeadPUBIC
AND
down
week/1
Peritoneal tattoo on
TUBERCLES
month/3months/6
ASIS BILATERALLY
Meticulous
closur
months
of peritoneal flap
with reduced
pressure to 7

RESULTS
Complication
s
Total number of cases from February 2003 to may 2015 = 261 cases

Pain

237 Males mean age 46

Numbness
24 Females mean age 32

Others

of hospital
forstay
less = mean Seroma = 1 on
Pain for less than a LengthNumbness
days = 12
than a2month
unilateral side male
month = 8 males
males
Pain 1-3 months = 3 Sick leave ( info available for Hematoma = 0
183 males
and 8 1-3
females) =
Numbness
males
months
= 4 males
mean
2 weeks
mean
Mesh migration = 0
Pain for more than 3
LoseNumbness
to follow more
up after 1
months = 0
Recurrence = 1 on
than
6
months
=
1
months 88 males 15 females unilateral side male
male
( found on 1 month
clinic visit )

CONCLUSION
However, while laparoscopic hernia repair requires a lengthy learning curve and is difficult to
learn and perform, it has advantages of less post-operative pain, early recovery with minimal
hospital stay, low post-operative complications, and recurrence.

contralateral occult inguinal hernia found at the time of laparoscopic transabdominal

preperitoneal patchplasty (TAPP) repair should also be repaired

A large case series of 2880 bilateral TAPP operations from a high-volume center revealed that
morbidity and reoperation rates were only marginally higher compared with 7240 unilateral TAPP
operation. On that scientific basis, laparoscopic/endoscopic repair of bilateral inguinal hernia was
recommended by the European Hernia Society, the International Endohernia Society, European
Association of Endoscopic Surgery and the Royal College of Surgeons of England (RCS
Commissioning guide: groin hernias 2013) .

Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal Hernia
[International Endohernia Society (IEHS)]http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3160575/

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