Overview
Definition:
Transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair is a minimally invasive surgical technique where a prosthetic mesh is placed to cover the defect in the transversalis fascia and peritoneum within the preperitoneal space, accessed laparoscopically through the abdominal cavity.
Epidemiology:
Inguinal hernias are common, affecting 1-5% of the general population, with a male predominance (9:1 ratio)
Recurrence rates after open repair can be significant, leading to the development of laparoscopic techniques
TAPP is one of the most frequently performed laparoscopic hernia repairs globally.
Clinical Significance:
TAPP offers several advantages over open repair, including reduced postoperative pain, faster recovery, shorter hospital stays, and potentially lower recurrence rates for bilateral or recurrent hernias
It is crucial for surgical residents and DNB/NEET SS aspirants to understand its indications, techniques, and complications for comprehensive surgical knowledge and patient management.
Indications
Primary Hernia:
Primary inguinal hernias (direct, indirect, or combined) in patients suitable for general anesthesia and laparoscopy.
Recurrent Hernia:
Recurrent inguinal hernias following previous open or laparoscopic repair, especially bilateral hernias.
Bilateral Hernia:
Simultaneous repair of bilateral inguinal hernias, offering efficiency and reduced recovery time.
Contraindications:
Absolute contraindications include inability to tolerate general anesthesia or pneumoperitoneum, extensive intra-abdominal adhesions, and active intra-abdominal infection
Relative contraindications may include severe coagulopathy or uncorrected bleeding disorders.
Preoperative Preparation
Patient Assessment:
Thorough medical history, physical examination, and assessment of comorbidities
Evaluation of anesthetic risk.
Informed Consent:
Detailed discussion with the patient regarding the procedure, potential risks (e.g., bleeding, infection, nerve injury, mesh-related issues, recurrence), benefits, and alternatives.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is typically required
Adequate muscle relaxation is essential for laparoscopic visualization.
Bowel Preparation:
Routine bowel preparation is generally not required for uncomplicated TAPP procedures, but specific surgeon preference may dictate otherwise.
Prophylactic Antibiotics:
Prophylactic intravenous antibiotics (e.g., a first-generation cephalosporin) are administered within 60 minutes of incision to reduce surgical site infection risk.
Procedure Steps
Access And Insufflation:
A small infraumbilical incision is made for the insertion of a veress needle or a trocar for CO2 insufflation to create a pneumoperitoneum (12-15 mmHg)
Additional ports (usually 2) are placed in the mid-clavicular line or anterior axillary line in the mid-abdomen.
Dissection Of Preperitoneal Space:
The peritoneum is incised laterally to the internal inguinal ring, and dissection of the preperitoneal space is carried out using laparoscopic instruments, extending superiorly, medially, and inferiorly to expose the pubic symphysis, Cooper's ligament, and the inguinal floor.
Hernia Sac Reduction:
The hernia sac and its contents are identified and reduced back into the abdominal cavity
If the sac is large or incarcerated, careful dissection and reduction are paramount.
Mesh Placement:
A large (e.g., 10x15 cm or larger) prosthetic mesh (e.g., polypropylene or dual mesh) is introduced laparoscopically and positioned to cover the entire myopectineal orifice, ensuring adequate overlap over the pubic bone, Cooper's ligament, and lateral to the internal ring.
Peritoneal Flap Closure:
The peritoneal incision is closed with sutures or surgical clips to create a tension-free space and prevent direct contact of the mesh with the bowel or omentum, thereby reducing the risk of adhesions and bowel obstruction.
Port Site Closure:
Trocar sites are closed with sutures if larger than 10 mm
Dressings are applied.
Postoperative Care
Pain Management:
Multimodal analgesia including oral or intravenous NSAIDs and acetaminophen
Opioids may be used sparingly for breakthrough pain
Regional blocks (e.g., ilioinguinal/iliohypogastric nerve block) can be considered.
Mobilization And Diet:
Early ambulation is encouraged to prevent deep vein thrombosis and aid recovery
Patients can usually resume a regular diet as tolerated once nausea and vomiting have resolved.
Discharge Criteria:
Discharge typically occurs on the same day or the day after surgery, provided the patient is pain-controlled, ambulating, tolerating oral intake, and has no signs of complications
Clear instructions for wound care and activity restrictions are provided.
Follow Up:
Follow-up appointments are usually scheduled at 2-4 weeks postoperatively to assess wound healing, pain, and return to normal activities
Long-term follow-up may be advised for monitoring recurrence.
Complications
Early Complications:
Bleeding (from epigastric vessels, Cooper's ligament, or trocar sites)
infection (superficial wound infection or deep mesh infection)
hematoma formation (in the preperitoneal space or scrotum)
urinary retention
seroma formation.
Late Complications:
Chronic groin pain (neuropathic pain due to nerve entrapment or irritation)
mesh infection or extrusion
mesh migration
recurrence of hernia
adhesion formation leading to bowel obstruction
phantom testis syndrome (rare).
Prevention Strategies:
Meticulous surgical technique with careful hemostasis
appropriate mesh selection and secure fixation (if needed)
adequate peritoneal flap closure
avoidance of excessive traction on nerves
prompt recognition and management of complications
judicious use of prophylactic antibiotics.
Key Points
Exam Focus:
TAPP involves peritoneal incision and closure
TAP repair (Totally Abdominal Preperitoneal) does not
Key anatomical structures to identify include the internal ring, external iliac vessels, vas deferens, and Cooper's ligament
Mesh placement is critical for tension-free repair.
Clinical Pearls:
Proper insufflation and port placement are crucial for adequate working space
Careful identification of the spermatic cord structures is vital to avoid injury
Exaggerated lithotomy or steep Trendelenburg position can improve visualization of the pelvis.
Common Mistakes:
Inadequate dissection of the preperitoneal space
insufficient mesh overlap
failure to identify and protect the vas deferens/testicular vessels
improper closure of the peritoneal flap leading to internal herniation or bowel entrapment
excessive manipulation of nerves causing chronic pain.