TAPP - Bilateral Direct Hernia

1. Abominal approach

Substep Structure Actions Specification

1A Skin Mark Mark the location of the subumbilical fold, the pubic tubercle and the two anterior superior iliac
spines.
The abdominal approach in the form of an open approach is described in more detail in the
specific course ‘Trocar placement’. In this case a closed approach is preferred and
a 10 mm and two 5 mm trocars are used.

TIP: Alternative trocar placement

An open approach can also be chosen, for instance if the patients abdomen has been previously
operated on.

Incise Incise the skin.

1B Abdominal wall Perforate Perforate the linea alba and the peritoneum with a Veress needle and perform a drop test to
confirm the entry into the abdominal cavity.

1C Abdominal cavity Insufflate Insufflate with CO2 until a pressure of about 12 mmHg is reached.

Introduce Introduce the camera trocar followed by the camera.

1D Abdominal wall Introduce Introduce the lateral trocars following a small incision on both sides lateral to the rectus muscle,
slightly proximal to the level of the umbilicus.

HAZARD: Trocar introduction

Be aware of the location of the epigastric vessels when introducing the lateral trocars.

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2. Peritoneal exposure

Substep Structure Actions Specification

2A Peritoneal cavity Identify Identify the following markers: the median umbilical fold, the medial umbilical folds, the
spermatic duct structures and the nature and size of the hernia(s).

2B Adhesions Dissect Dissect only the adhesions between the bowel and peritoneum that might obstruct the exposure
or access to the hernia sites. The dissection is not always necessary and carries risk of additional
injury to the bowel.

2C Bowel Repostition Reposition the contents of the hernial sac back into the abdomen if necessary. Sometimes it is
necessary to use blunt or sharp dissection.

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3. Pre-peritoneal dissection

Substep Structure Actions Specification

3A Peritoneum Incise The peritoneal incision is placed 3–4 cm above all possible defects from the anterior superior
iliac spine to the medial umbilical fold. If more space is needed, extend the incision cranially,
parallel to the medial umbilical fold.

Dissect Dissect the transversalis fascia from the ventral side of the peritoneum. The extent of dissection
should reach 1–2 cm beyond the pubic symphysis to the contralateral side, cranially 3–4 cm
above the transversalis arch or any direct defect, laterally to the anterior superior iliac spine, and
caudally minimally 4–5 cm below the ileopubic tract at the level of psoas muscle and 2–3 cm
below Cooper’s ligament at the level of superior arch of the pubic bone.

HAZARD: Corona mortis

Take care not to damage the corona mortis; an anastomosis between the obturator vessels and
external iliac vessels posterior to the pubic bones. When damaged, the vessel will retract into the
obturator foramen, making it very difficult to find the bleeding and subsequently stop it.

HAZARD: Triangle of Pain

This area is characterized by the presence of larger nerves (the genito-femoral nerve with its two
branches, more laterally the ilioinguinal nerve and the iliohypogastric nerve) which run deep into
the endo-abdominopelvic fascia.

TIP: Dissection starting point

To help determine where to start the peritoneal dissection, press on the iliac spine on the
outside and use this as a mark with respect to the medial umbilical ligament.

TIP: Peritoneal dissection

Work from a lateral to a medial direction, making the dissection of the underlying tissue much
easier.

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4. Peritoneal dissection

Substep Structure Actions Specification

4A Peritoneum Dissect In an indirect hernia: dissect the hernial sac from the spermatic cord.
In a direct hernia: dissect the hernial sac out of the defect.
If the hernia is bilateral, first finish dissection on one side and after dissection of the other side
join the two planes to create one complete pre-peritoneal space.

TIP: Sac transection

In case of a large hernia sac, transect the sac.

HAZARD: Triangle of Doom

The “Triangle of Doom” is bound laterally by the spermatic vessels, and medially
by the vas deferens in the male, or the round ligament of the uterus in the female. Structures in
this triangle are the external iliac artery and vein and the genital branch of the genitofemoral
nerve.

4B Lipoma Identify Inspect for the presence of a lipoma of the cord. If it is, removing it will reduce the chance of
pseudo-recurrence.

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5. Mesh placement

Substep Structure Actions Specification

5A Mesh Introduce Introduce a rolled up mesh of at least 10 x 15 cm into the abdominal cavity through the umbilical
port. Let the mesh expand and position it directly over the cord structures, overlapping the pubic
tubercle and the hernia port (cover Fruchauds area).

TIP: Mesh introduction

Preferably finish all of your dissection before inserting the mesh since the dissection is more
difficult to perform with the mesh blocking your way and decreasing your vision.

Fixate Fixate the mesh. This can be achieved by using different methods (sutures, staples, glue),
depending on the surgeon’s preference.

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6. Peritoneal closure

Substep Structure Actions Specification

6A Peritoneum Close Close the peritoneum (eg. with a self retaining suture). It is possible to reduce the
intra-abdominal pressure to facilitate the peritoneal closure during suturing.

6B Peritoneal cavity Desufflate Desufflate under vision, then remove the trocars.

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7. Wound closure

Substep Structure Actions Specification

7A Linea alba Close Close the linea alba with absorbable sutures.

7B Skin Close Close the skin with absorbable sutures.

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