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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
83
Epigastric vessels
9
Umbilicus 5 mm Optic
5/7 mm
Groin right
. Fig.9.4 Standard positioning of the ports in right-
sided hernia
5 mm
Groin left
3. Recently a 5mm 30° optic nearly as eective
as the 10mm is available. Insofar, actually our
standard is (. Fig.9.4) (1) 5mm optic at the
umbilicus, (2) 5mm working trocar le midclavicular line at the level of umbilicus, and
(3) 7mm plastic working trocar right MCL
at the level of umbilicus (. Figs.9.2 and 9.4).
Advantages of this minimized approach: excellent cosmesis, less pain, and no trocar hernias.
Plica umb. med.
Hesselbach
triangle
Ductus deferens
. Fig.9.5 Laparoscopic view of the right inguinal region
Plica umb.
medialis
Iliac artery
Inner ing. ring
Epigastric vessels
D. deferens
Testicular vessels
Ileo-pubic
tract
Testicular vessels
Spina iliaca
anterior sup.
In unilateral hernia we recommend insertion of
the ipsilateral working trocar about 2–3cm above
the naval area and the contralateral working trocar 2–3cm below the umbilical level (
. Fig.9.4).
In this way, collisions with the optic trocar can be
minimized. In bilateral hernia both working trocars are positioned at the same level.
Diagnostic Round View
In contrast to TEP, the transabdominal technique
allows immediate assessment of the hernia situation– unilateral or bilateral, occult contralateral
hernia, direct or indirect, size of hernia defect,
hernia content, and other abdominal pathology.
Operation: Complete Dissection
ofthePelvic Floor
Step 1 Identifying the anatomical structures
(. Fig. 9.5) and cross-checking with the camera
guide (assistant). Precise knowledge of anatomy is an
indispensable precondition for the success of the
operation and for avoidance of complications. Spina
. Fig.9.6 Wide opening of the peritoneum along the
black line
iliaca ant. sup. is identied by palpation from outside. If there are adhesions between the omentum or
the bowel and the hernia sac, it is not recommended
to take it down– this is unnecessary and carries the
risk for lesion of bowel. Adhesions are removed “en
bloc” together with the peritoneum when opening
it to enter the preperitoneal space. Adhesiolysis is
only indicated if you cannot approach the inguinal
region because of severe adhesions in the lower
abdomen, but in these cases special expertise in
laparoscopic surgery is demanded.
Enter the preperitoneal space by performing a
wide incision of the peritoneum (
. Fig.9.6), start-
ing at spina iliaca ant. sup. e incision is placed
3–4 cm above all possible hernia openings and
ends at the plica umbilicalis medialis. e plica is
not cutted (danger for bleeding from occasionally
open umbilical artery). If you need more space, go
parallel to the plica cranially.
84
R. Bittner et al.
Plica umb. med.
Spina
. Fig.9.7 Dissection of the preperitoneal space of
Retzius
Epigastric vessels
. Fig.9.9 Right inguinal region: start of the dissection
laterally in the region of spina iliaca ant. sup.
9
Ileo-pubic
tract
N. cut. fem. Lat.
Space of Bogros
Testicular vessels
with fatty tissue
. Fig.9.8 Left inguinal region: lateral preperitoneal
space of Bogros and inner inguinal ring
Step 2 When continuing the dissection, follow a
precise strategy. is is especially important in complicated hernias (e.g., scrotal). Aer entering the
preperitoneal space, start rst with the dissection of
the medial compartment (. Fig. 9.7 – spatium
Retzii) and/or the lateral compartment (. Fig.9.8–
spatium Bogros). Sometimes if dissection in front of
the rectus muscle can be dicult due to additional
fascial tissue belonging to fascia transversalis, then it
is better to start lateral (. Fig.9.9), identify the ana-
tomical structures (e.g., iliopubic tract, transversalis
arch, epigastric vessels), and dissect medially aerward. e dissection can be done mainly blunt in an
avascular plain, called “spin-web” like tissue zone
(. Figs.9.7 and 9.9). Develop tissue feeling when
doing blunt dissection. If you are in the right plain,
it is an easy and fast procedure. If there is some
bleeding, we use monopolar electric very meticu-
. Fig.9.10 Left inguinal region: space of Bogros with
lumbar/spermatic fascia protecting the inguinal nerves
lously, so that the operation eld always is free of
blood and has a yellowish-pink color. e peritoneum with its surrounding preperitoneal fatty tissue will be pushed away from the fascia transversalis
and the rectus muscle. Keep in mind: e aim of the
dissection is a nearly fatty-free abdominal wall
exposing all important anatomical structures, but
the aim is not to attain a fatty-free peritoneal ap.
Following the described technique, damage to the
peritoneum which may result in large tears can be
avoided, and closure of the peritoneal ap aer
mesh implantation will become more easy.
When dissecting the lateral caudal compartment below of the iliopubic tract, it is essential
to respect the fascia spermatica/lumbar and
especially a thin membrane dividing the retroperitoneal space in a visceral and parietal compartment (
. Fig. 9.10). e nerves are located
Psoas muscle
Testicular vessels
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
85
9
Direct hernia sac
Symphysis
transversalis fascia
. Fig.9.11 Preperitoneal space of Retzius and a direct
hernia sac
Testicular vessels
with fatty tissue
. Fig.9.12 Right inguinal region, medial compartment.
Pseudosac-like enlarged fascia transversalis
in the parietal space behind this membrane, and
so they are protected by these fascial structures
which must not be interrupted by rough operating technique.
Step 3 In case of direct hernia when dissecting
the medial compartment, you will nd the direct
hernia sac easily (. Fig. 9.11a). At once you can
take down all the fatty tissue forming the hernia
content and expose the pseudosac-like enlarged fas-
cia transversalis (
. Fig.9.12). When doing this step,
use electrocoagulation very generously to close all
even the smallest blood and lymphatic vessels.
Applying this technique you can prevent serohematoma formation later on. In very large hernia
pseudosacs, in order to avoid any dead space
(which may promote sero-hematoma signicantly)
Epigastric vessels
Symphysis
. Fig.9.13 Suprapubic hernia opening in recurrent
hernia after previous Lichtenstein repair
Cord structures
A. iliaca
in the former bed of the hernia, it is recommended
to invert the sac and to x it to Cooper’s ligament by
suture or tacks [3, 4] or close the sac by using a
Roeder sling.
Two further basic principles are to be taken
into account when dissecting the medial compartment:
1. Dissection has to go beyond the middle of
the symphysis to the opposite side in order
to identify a suprasymphytic hernia orice
. Fig.9.13), not uncommon in recurrence
(
aer Lichtenstein, and also to create a large
enough space for plain and wrinkle-free
placement of a large mesh. Usually this preparation is simple and carries no risk for an
injury of urinary bladder. Problems may be
expected, however, in cases of previous operations in this area (e.g., prostatic resection).
Due to the signicant risk of bladder injury,
such operations should only be performed by
very experienced laparoscopic surgeons; oth-
erwise an open approach should be chosen
from the start.
2. In the direction toward lateral, the medial
compartment should be dissected as far as the
iliac vessels, in order to clear the femoral hernia site (. Fig.9.14). Preparation should be
done very carefully to avoid any injuries not
only to the iliac vessels but also to “corona
mortis,” being present in 20–30% of cases
(. Fig.9.15).
Step 4 Dissection of the lateral compartment is
signicantly more dicult, especially in patients
with a large amount of fatty tissue accompanying
a large indirect hernia sac and in patients with
86
R. Bittner et al.
Epigastric vessels
Symphysis
Cord structures
Femoral defect
. Fig.9.14 Exposition of a femoral hernia site
Vasa epigastrica
a
Urinary
bladder
b
Epigastric vessels
Adhesions between cord
structures and epigastr.
vessels, transversalis
arch and ileopubic tract.
Ileopubic tract
9
Corona mortis
Ductus deferens
. Fig.9.15 Dissection of the medial compartment:
corona mortis
dense scar tissues between hernia sac and cremasteric muscle. To do dissection of a large hernia
sac safely, a rst rule demands to perform fattyfree dissection of the inner inguinal ring
(. Fig.9.16a, b, c) and identify all important anatomical landmarks (epigastric vessels, transversalis arch, tractus iliopubicus, symphysis, and
Cooper’s ligament). A second rule demands in
unclear topography of hernia sac and surrounding
fatty tissues to identify rst the testicular vessels in
the farthest caudal- lateral part of the lateral compartment (. Fig.9.17) and use these vessels as
guiding landmark for dissection of hernia sac.
c
A. iliaca
. Fig.9.16 a, b, c Right inguinal region: rst rule–
clearance of the inner inguinal ring
e third rule concerns cord lipomas (
. Fig.9.18).
In these cases it is recommended rst to reduce the
lipoma, and then very oen the hernia sac is
reduced too. In any case all lipomas have to be
reduced.
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
87
9
Epigastric vessels
:
Symphysis
Testicular vessels
Peritoneum
. Fig.9.17 Right inguinal region: second rule– identi-
fying of testicular vessels far caudal/lateral
Epigastric
vessels
Symphysis
Femoral
vein
Lipoma
Tractus ileo-pubicusa
GB
FB
GN
b
. Fig.9.19 a Space of Bogros: course of n. cutaneous
fem. lateralis (LC), n. genitofemoralis (GN), and n. ilioinguinalis (IL) in cadaver dissection (according to Anni-bali). b
Space of Bogros: course of n. cutaneous fem. lateralis (LC),
n. genitofemoralis (GN), and n. ilioinguinalis (IL) during
laparoscopic dissection
LC
IL
. Fig.9.18 Right inguinal region: third rule– reduction
of cord lipomas
Special attention must be paid when performing dissection underneath the level of the iliopubic
tract, in order to avoid injury to the nerves (n. cutaneous fem. lat., n. genitofemoralis (. Fig.9.19a, b))
or vessels. Clumsy and unprecise use of electrocoagulation and placements of clips are strictly
prohibited in this region.
Step 5 Dissection of an indirect hernia sac
(. Fig.9.20) is much more dicult compared to
the direct sac due to the very close relationship to
the cord structures. Dissection is mainly blunt,
adhering strictly to the hernia sac with careful
hemostasis and visualizing the testicular vessels
continuously (. Fig. 9.21). e dissection is car-
ried out parallel to the testicular vessels in a
Inner inguinal ring
Epigastric vessels
Transvers.
arch
Ileopubic tract
Hernia sac
. Fig.9.20 Dissection of an indirect hernia sac after
identifying the anatomical structures (e.g., ileopubic tract,
transversalis arch, epigastric vessels)
medial-ventral direction to the angle between the
iliopubic tract and epigastric vessels. If there are
very dense adhesions between hernia sac and the
88
R. Bittner et al.
Hernia sac
Vasa epigastrica
Ductus deferens
Testicular vessels
Hernia sac
Dissection line
. Fig.9.21 Dissection of an indirect hernia sac
. Fig.9.23 Start of the parietalization after approach-
ing the top of the hernia sac
Once the top of the hernia sac has been
reached, the rest of the procedure is simple. All
9
Hernia sac
Ductus deferens
adhesions between the hernia sac and the cord
structures have to be taken down (
. Fig. 9.23).
Mostly blunt, partly sharp (very supercial electric) dissection is now carried out in the direction of the abdominal cavity. e hernia sac and
Testicular vessels
the peritoneum are completely detached from
the cord. is procedure is known as parietal-
ization. It should provide fold- and wrinkle-free
Peritoneum
placement of a large mesh with direct contact to
spermatic fascia without any fat located in between
. Fig.9.22 Creation of a window between the hernia
sac and the cord structures
(. Fig. 9.24a, b). e parietalization should go
down to the mid-psoas muscle laterally and
medially to the point the vas turns down to the
cremasteric tube or the cord structures, then
these are carefully dissected by supercial use of
electrocoagulation, and then they can be pushed
away easily. If the hernia sac is very long, it may
need a strong tug with the le hand holding the
Endo-Overholt to remove the hernia sac from its
bed in the inguinal canal. To prevent the hernia
sac from slipping back, we recommend dissection
with two Endo- Overholts using the so-called
rope-ladder technique. It can sometimes be helpful to create a dorso-caudal window between her-
prostate gland. Later manipulation of the perito-
neum must not lead to a change in the position of
the cord structures. e same should be true with
the mesh aer its placement.
Aer this dissection, the entire myopectin-
eal orice is free of peritoneum and fatty tissue,
thereby allowing complete identication of epi-
gastric vessels, internal inguinal ring, Hesselbach’s
triangle, Cooper’s ligament, symphysis, iliopubic
tract, testicular vessel bundle, and vas deferens
. Fig.9.25).
(
nia sac and cord structures, especially in the case
of scrotal hernia (
. Fig.9.22). If complete removal
of hernia sac may seem too dicult with respect to
the risk of injury to the spermatic cord, then the
hernia sac can be severed. In this case proximally
the hernia sac should be closed by suture, distally
le open.
Step 6 Implantation of a lightweight mesh (below
50 g/m2) with large pores (>1 mm) and at least
10×15cm in size. e mesh will be pushed like an
umbrella through a 10/12mm trocar with the help
of a blunt Reddick-Olsen clamp or like a coat wrap-
ping the clamp through a 7 mm trocar. It will be
ab
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
89
9
Cord
Symphysis
Duct
Vessels
Peritoneum lateral
Peritoneum
. Fig.9.24 a, b Parietalization: detachment of all adhesions between the peritoneum and the cord structures/fascia
spermatica (following the arrows)
testicular vessels
Adhesions between
peritoneum and
fascia spermatica
Myopectinal orifice
acc. to Fruchaud
. Fig.9.25 Right inguinal region after complete
dissection
. Fig.9.26 Placement of mesh without any folds
placed absolutely at without any folds or wrinkles
covering the whole myopectineal orice with an overlap of all possible hernia openings of at least 3–5cm
(. Fig.9.26). ere is a basic rule: “e larger the
defect is, the mesh should be more sti, larger, and
more overlapping.”
sary. In indirect hernia defects (>4–5cm), we recommend a noninvasive xation with glue. Fixation
with glue is possible in the triangle of doom and
. Fig.9.27). In larger direct hernial defects
pain (
(>3 cm), we recommend xation with tacks
(absorbable). Recommended tack position: 2–3 to
Cooper’s ligament, one or two to the rectus mus-
Step 7 TAPP works according to the principle of
Pascal [6]. Insofar xation is not necessary for stabilization of reconstruction but only for prevention
of dislocation in the very early postoperative period
when the patient is starting heavy coughing, pressing, and moving. Our recommendation: In very
small hernia defects (<3cm), xation is not neces-
cle, and one or two lateral to the epigastrics about
4cm high above the iliopubic tract to avoid any
damage to the nerves. But always keep in mind that
xation cannot compensate insucient dissection
technique or inadequate mesh size. In very large
hernia defects, a larger mesh (12× 17) is recommended too [3, 4].
90
R. Bittner et al.
A
B
C
A
Triangle of doom (A) - Triangle of pain (B)
9
. Fig.9.27 Fixation of mesh with glue
B
2
8
= points of application
could give reason for small bowel ileus. Suturing
may be in the beginning more dicult and time-
consuming, but it produces less pain in compari-
son to clip or tack closure. To facilitate tension-free
closure, the intra-abdominal pressure may be
reduced to 6–8 mmHg. When using this tech-
nique, a tight and safe seal is possible even with
scarred peritoneum.
at least 1 to 2 cm
Lipoma
Step 9 Finally the working trocars are removed
under direct visualization. Even though blunt
Peritoneum
trocars are used, bleeding from epigastric ves-
sels may occasionally occur and must be recog-
nized and controlled. Suturing of lateral fascial
. Fig.9.28 When elevating the peritoneum for closure,
the mesh must not move
openings caused by the trocars is usually not
necessary, but the incision at the naval when
used trocars are equal to or larger than 1cm
Step 8 Before the peritoneum is closed, it is lied
and the extent of parietalization is checked. e
covering peritoneal fold should be at least 1–2cm
distal of the lower edge of the mesh which should
not move when elevating the peritoneum
(. Fig.9.28). e peritoneum should meticulously
be closed by absorbable running suture
(. Fig. 9.29). e suturing has to be absolutely
without any gaps, because gaps larger than 1cm
should always be closed carefully with suture to
avoid trocar herniation in the late postoperative
course.
Own results, inclusive “learning curve” in
15,101 consecutively operated on, unselected her-
nia repairs in the TAPP technique (1993–2007), are
operating time, 40min; morbidity, 2.5%; mortality,
0,007%; reoperation rate, 0.44%; time of disability
of work, 14days; and recurrence rate, 0.7%.
Transabdominal Preperitoneal Patch Plasty (TAPP): Standard Technique
. Fig.9.29 Closure of the peritoneum by absorbable running suture
91
9
9.2 Evidence-Based Management
inTAPP (J.Kukleta [3, 4])
9.2.1 Preparation ofthePatient
When Is theUrinary Bladder Catheter
Recommended?
Statements
If the patient does not empty his/her urinary
bladder, the operation may be more dicult
with a higher risk of bladder injury; however,
perioperative catheterization of urinary
bladder is very rarely necessary.
Recommendations
5 Grade B (upgraded): It is recommended
that the patient empty his/her bladder
immediately prior to the operation
5 Grade C: Restrictive pre- and postopera-
tive intravenous fluid administration
reduces the risk of postoperative urinary
retention
Full urinary bladder can increase substantially
the technical diculty of TAPP repair [7, 8].
In order to diminish the risk of bladder injury,
the bladder should be emptied before surgery.
Predisposing factors for an injury are a full bladder or a previous exposure of the retropubic
space particularly aer prostate interventions,
irradiation, or preperitoneal mesh/plug implantation [9]. e amount of intravenous intraoperative uid administered is a signicant risk factor
for urinary retention [10].
9.2.2 Establishing
Pneumoperitoneum
Which Is theSafest andMost Eective
Method ofEstablishing
Pneumoperitoneum andObtaining
Access totheAbdominal Cavity?
Statements
5 Level 1A: There is no definitive evidence
that the open-entry technique for establishing pneumoperitoneum is superior or
inferior to the other techniques currently
available
5 Level 2C: Establishing pneumoperito-
neum to gain access to the abdominal
cavity represents a potential risk of
parietal, intra-abdominal, and retroperitoneal injury
5 Patients after previous laparotomy,
obese patients, and very thin patients
are at a higher risk
5 Level 4: The various Veress needle safety
tests or checks provide insufficient
information about the placement of the
Veress needle but should remind that
maximal caution is required
92
R. Bittner et al.
in this procedure; however, waggling of the Veress
5 The initial gas pressure when starting
insufflation is a reliable indicator of correct intraperitoneal placement of the
Veress needle
5 Left upper quadrant (LUQ, Palmer’s)
laparoscopic entry may be successful in
patients with suspected or known periumbilical adhesions or after failed insufflation attempts at the umbilicus
needle from side to side must be avoided, as this
can enlarge a 1.6mm puncture injury to an injury
of up to 1cm in viscera or blood vessels [14]. e
angle of the Veress needle insertion should vary
according to the BMI of the patient, from 45° in
nonobese to 90° in obese patients.
Although the open approach seems to be the
safest, especially in patients aer previous periumbilical surgery, it does not eliminate completely
the risk of injury [16] (Level 2C). In 12,919 cases,
access morbidity was in 12,919 cases: Hasson
0.09%, Veress +1st trocar 0.18%, and optical
Recommendations
5 Grade A: When establishing pneu-
moperitoneum to gain access to the
abdominal cavity, extreme caution is
required. Be aware of the risk of injury
5 The open access should be utilized as
an alternative to the Veress needle tech-
9
nique in patients after previous open
periumbilical abdominal surgery
trocar 0.29%.When using open approach palpation through the peritoneal aperture, to exclude
adhesions is mandatory before inserting a blunt
cannula [17]; however, when using miniaturized
instruments (5mm optic trocars), this is impossible.
ere is no evidence that the open-entry technique is superior or inferior to the other entry
techniques currently available. One RCT recommends open access as a standard for laparoscopic
operations, but the number of only randomized
To create pneumoperitoneum to gain access to
the abdominal cavity carries a risk of injury. e
safest and most ecient method of access is still
controversial.
ere are four ways to obtain access to the
abdominal cavity: (1) open access (Hasson), (2)
Veress needle to create pneumoperitoneum and
trocar insertion without visual control, (3) direct
trocar insertion (without previous pneumoperitoneum), and (4) visual entry with or without
previous gas insuation.
Among general surgeons and gynecologists,
the most popular method is the Veress needle
[11]. To increase the safety and minimize the
morbidity of this method, several safety tests were
proposed by Semm [12, 13]. e literature does
not always support the use of these tests as they
provide very little useful information about the
placement of the needle [14]. e intraperitoneal
pressure initially induced by the gas insuations
seems to be more important to control the correct
placement of the Veress needle [15]. If the pressure is initially higher than 2–3mmHg, then the
needle is not placed correctly.
erefore, it might not be necessary to perform various safety checks when inserting the
Veress needle, but their routine use may still
remind the surgeon of the risk of injury involved
50 patients is too small to allow denite conclusions [18].
ere are few reports suggesting direct trocar insertion without previous gas insuation
[19, 20]. e benet, it is argued, is to diminish
the potential morbidity of the Veress needle and
to create pneumoperitoneum faster. e new
designs of blunt tip trocars promise to decrease
the number of minor injuries (subcutaneous,
preperitoneal gas insuation, needle tip injuries
intra- and retroperitoneally) while maintaining
the incidence of major injuries equally low as the
Veress needle.
e visual entry trocars may oer an advantage over traditional trocars, as they allow a clear
optical entry, but this advantage has not been
fully explored. ey also minimize the size of the
entry wound and reduce the force necessary for
insertion, but they are not superior to other trocars since they do not avoid visceral and vascular
injury completely.
A systematic review of the safety and eectiveness of methods used to establish pneumoperitoneum in laparoscopic surgery (2003) could not
demonstrate any signicant dierence to support
one method of choice [21].
e method of approach has to be adapted
to patient’s condition in case of expected