Transabdominal anterior peritoneal repair (TAPP)
Anesthesia and position
Endotracheal intubation with general anesthesia is recommended.
Head low and feet high 10 to 15 degrees in the horizontal position. The operator is positioned on the contralateral side of the affected side for the procedure, and the assistant is positioned on the affected or cephalad side to hold the scope. The monitor is placed directly under the operating table.
Surgical steps
I. Trocar puncture
The umbilical rim is punctured and a CO2 pneumoperitoneum is established to 15 mm Hg. Three trocars are routinely placed: a 10-12 mm trocars in the umbilical hole to place the 30-degree laparoscopic tip, and a 5 mm trocars at the level of the flat umbilicus on the lateral rectus abdominis muscle as the operating hole. In the case of unilateral hernia, the contralateral trocar can be placed in the position below the umbilicus at the lateral border of the rectus abdominis muscle.
II. Abdominal cavity exploration
After entering the abdominal cavity, five folds and two traps and subabdominal vessels are first identified: the mid-umbilical fold, the medial umbilical fold, the lateral umbilical fold, and the subabdominal artery behind the lateral umbilical fold. These five folds divide the preperitoneal area into three fossae: supravesical fossa, medial fossa, and lateral fossa, to observe the site, size, and contents of the hernia as well as the presence of a contralateral “occult hernia”, and to record the type and staging of the hernia.
C. Peritoneal incision
The peritoneum is incised at the superior edge of the hernia defect from the medial umbilical fold to the anterior superior iliac crest, and the peritoneal flap at the superior and inferior edges is freed to enter the anterior peritoneal space. Be careful not to exceed the medial umbilical fold medially to avoid damaging the bladder, and avoid damaging the inferior abdominal wall artery when incising the peritoneum in the middle.
IV. Treatment of hernia sacs
1. Hiatal hernia sac: It is located on the lateral side of the inferior abdominal wall artery and enters the inguinal canal from the inner ring mouth, with the vas deferens and spermatic vessels behind it. The hernia sac is pulled from the inguinal canal into the abdominal cavity, and the sac is separated from the level of the internal annulus by about 5-6 cm from its posterior spermatic vessels and vas deferens. The purpose of “perietalization of the spermatic cord” is to ensure that a large enough patch can be laid flat on the spermatic cord component without curling. In some large, long-standing hiatal hernia sacs with dense adhesions to the spermatic cord, it is not necessary to forcibly dissect the sac, but rather to transect it, leaving the distal end open and completing the ventralization of the spermatic cord proximally. In the process of stripping the hernia sac, any “lipoma” outside the hernia sac should be removed, otherwise the “lipoma” will slide into the inguinal canal and cause recurrence similar to “extraperitoneal slip hernia”.
Direct hernia sac: located in the rectal hernia triangle inside the inferior abdominal wall artery, it is easier to handle, only the peritoneal flap (hernia sac) and the preperitoneal fatty nodal tissue need to be completely retracted from the rectal hernia triangle. All the hernia sacs of direct hernias can be completely retracted without transection. The apparent thickening of the transverse abdominal fascia at the site of the hernia defect is called a “pseudohernia sac” and should not be misidentified and forcibly removed.
Femoral hernia hernial sac: The principles of treatment are the same as those for direct hernia. After completing the dissection of the triangle of straight hernia, the femoral ring should also be examined. In femoral hernias, the hernia sac and preperitoneal fat are often embedded in the femoral ring. If retraction is difficult, the iliopubic bundle between the direct hernia and femoral hernia can be loosened and the embedded tissue retracted.
V. Anatomy and extent of separation of the preperitoneal space
After adequate freeing of the hernia sac, the posterior lateral spermatic vessels and the medial vas deferens can be seen, and the two meet at the mouth of the internal ring and enter the inguinal canal. The triangular gap enclosed by the spermatic vessels and the vas deferens is crossed by the external iliac artery, called the Doom triangle, where excessive separation and stapling of the patch are strictly prohibited, otherwise fatal bleeding may occur. Continuing medially into the pubic bladder gap (Retzius gap), the entire pubic symphysis and pubic comb ligament (Cooper’s ligament) are dissected and exposed. The Bogros space and the iliac fossa space were accessed by separating laterally. When separating the iliac fossa space, care is taken not to damage the nerves within the “pain triangle”, which is located lateral to the spermatic vessels and inferior to the iliopubic bundle and is crossed by the lateral femoral cutaneous nerve and the femoral branch of the genitofemoral nerve.
The separation of the anterior peritoneal space is approximately: medial to the pubic symphysis and over the midline, lateral to the iliopsoas muscle and anterior superior iliac spine, superior to 2-3 cm above the symphysis tendon, inferior to about 2 cm below the pubic commissure ligament, and inferior to about 5-6 cm below the ventral wall of the spermatic cord component. this separation is to ensure that a large enough patch can be placed. In female patients, the round ligament of the uterus is densely adherent to the peritoneum and often requires cutting the round ligament of the uterus.
VI. Coverage of the patch.
The principle of patch repair is to replace the transverse abdominal fascia to cover the entire musculo-pubic foramen and to have some overlap with the surrounding muscular and bony tissues. That is, the scope of patch coverage should include the above-mentioned range of separation of the preperitoneal space, specifically, the upper part of the patch should cover the joint tendon 2-3 cm, the outer part should reach the anterior superior iliac spine, the inner part must cover the rectus abdominis and pubic tuberosity and exceed the midline, the inner part below should be inserted into the pubic bladder space and not directly cover the bladder, and the outer part below must achieve the spermatic cord component of ” ventralization”. A 10 cm by 15 cm patch is often required. In female patients, if the round ligament of the uterus is not cut, the patch should be cut with an opening so that the round ligament of the uterus passes through and then sutured.
VII. Fixation of the patch.
There are different views on whether the patch needs to be fixed or not. In order to avoid complications and pain, medical adhesive is preferred to fix the patch. If sutures or hernia staples are used, care must be taken that only four structures are available for fixation of the patch: the joint tendon, the rectus abdominis muscle, the trap ligament and the pubocococcygeal comb ligament. It is strictly forbidden to staple the patch in the danger triangle, crown of death, or nerve region.
VIII. Closure of the peritoneum: sutures or hernia fixators can be used to close the peritoneum. Postoperatively, the peritoneum is carefully probed for tight closure and closure of the transected hernia sac to avoid postoperative intestinal adhesions.
Postoperative management
A liquid or semi-liquid diet is resumed 6 hours after surgery, and a general diet is resumed 24 hours after surgery. The patient can be discharged from the hospital 24 hours after surgery.