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Fig. 29.14 Rolled mesh
plug
Fig. 29.15 RutkowRobbins hand-rolled cone
A. Bates and S. Docimo Jr.
add bulk to the repair (Fig.29.16). The plug was secured to the ring of the defect
using eight to ten Vicryl sutures. Along with the plug, a 3cm×6cm at mesh was
included for the patch. For small defects, including femoral defects, petals could be
removed from the plug to decrease its size. Furthermore, the plug was offered in
multiple sizes to customize the repair for patient habitus and defect morphology.
Rutkow and Robbins had effectively streamlined and standardized open inguinal
hernia repair. They performed over 3200 mesh plug repairs, including over 1500
PerFix plug repairs. They reported a less than 1% recurrence for primary hernias
and 3% recurrence for recurrent hernias. However, once multiply recurrent, they
recommended alternative repairs due to a recurrence rate of 9% with the PerFix
technique [17]. That said, the PerFix repair remains one of the most common inguinal hernia repairs performed today.
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
Fig. 29.16 Bard PerFix
plug-and-patch
411
Complications ofthePlug-and-Patch
Many complications have been reported with the mesh plug, partially to no fault of
the device itself. Many surgeons have modied the technique that was standardized
by Rutkow and Robbins, and it can be assumed that many complications are attributable to improper technique. There are multiple reports of mesh erosion and migration [18–20]. Erosion has been reported into the urinary bladder, colon, small bowel,
and iliac vessels, causing signicant morbidity.
The issue of mesh migration may be attributable to mesh shrinkage. During
incorporation and scarring, synthetic mesh will lose approximately 20% of its surface area. When shaped as a cone, this shrinkage may result in up to a 70% reduction in plug volume [21].
Postoperative chronic groin pain is a complex entity whose etiology is difcult
to elucidate. Many surgeons have attributed groin pain in some patients to the mesh
material itself. However, it is our belief that the inguinal dissection and placement
of the mesh is the main determinant of postoperative groin pain. For example, the
protection of at-risk nerves within their investing fascia while performing a dissection with minimal tissue trauma will help protect the majority of patients from postoperative groin pain.
Post-herniorrhaphy Inguinodynia
Post-herniorrhaphy inguinodynia can be divided into nociceptive pain and neuropathic pain. Nociceptive pain is caused by tissue injury or inammatory reaction.
These signals originate at nociceptors in the tissues themselves and travel to the
brain via A-delta and C-bers. The use of local anesthesia also helps control the
production of nociceptive molecules.
412
A. Bates and S. Docimo Jr.
Neuropathic pain is caused by direct nerve injury. These injuries include myelin
separation, axon crystallization, and other structural changes [22]. They can be
caused by direct mesh-to-nerve contact or nerve entrapment from sutures, tacks, or
folded mesh. The proper positioning of mesh and the protection of at-risk nerves
within investing fascia help protect the nerves from iatrogenic injury and mesh contact, which can lower the risk of inguinodynia from 6–8% to 1% [23].
Outcomes ofOpen Techniques
Despite a drop in recurrence rates among tension-free repairs, concerns regarding
the use of prosthetic material have been raised. Chronic groin pain (>3months) or
inguinodynia is a clinically challenging complication following hernia repair [24].
Attempts at limiting postoperative pain have been made. A self-gripping mesh,
which eliminates the need for sutures or tacs, demonstrated a decrease in short-term
pain (<1year postoperatively) [25, 26]. However, an increase in recurrences following the use of self-gripping meshes has been reported [24, 27, 28].
Due to the widespread use of hernioplasty, tissue repairs have fallen by the wayside in most surgical residency programs. However, in certain settings, such as a
contaminated surgical eld or patient objection to mesh, the knowledge of various
tissue repair techniques and their outcomes is paramount. Currently, data supports
the Shouldice technique as the tissue repair of choice, compared to Bassini and
McVay. The recurrence rate of a Shouldice repair has been typically reported to be
in the range of 1–5% in well-selected patients [29–31]. A 2009 Cochrane review
demonstrated a lower pooled recurrence rate for the Shouldice repair compared to
other tissue repairs (odds ratio, 0.62; 95% CI 0.45–0.85) [31]. Comparison of the
Shouldice technique to mesh repairs demonstrated a longer postoperative hospital
stay (not signicant) for the tissue repair and signicantly reduced recurrences
(3.6% vs. 0.8%) among the mesh repairs [32].
Overall, the best outcomes for a Shouldice repair are typically achieved in the
hands of those well trained in the technique. Malik et al. evaluated 235,192
Ontario residents who underwent primary elective inguinal hernia repair at either
a hernia specialty hospital (Shouldice Hospital) or a general hospital. Patients at
the Shouldice Hospital had an age-standardized recurrence risk of 1.15% (95% CI
1.05–1.25%) in contrast to recurrence of 4.79% (95% CI 4.54–5.04%) at the highest volume general hospitals [33]. Compared to the Bassini and McVay repairs,
the Shouldice technique also remains superior. The recurrence rate for Bassini
repairs has been quoted as high as 21% [34]. A prospective study comparing the
use of Bassini and McVay tissue repairs with a follow-up range of 10–208months
demonstrated a recurrence rate of 2.67% in the McVay group and 2.89% in the
Bassini group [34]. Due to the higher recurrence rate following the Bassini and
McVay repair, the Shouldice technique remains the preferred method of tissue
repair [1].
Synthetics, such as polypropylene, ePTFE, and polyesters, were heralded as a
major breakthrough in the tension-free repair of inguinal hernias with the promise to
29 Open Techniques: Mesh andNon-mesh Anatomical Repairs
413
limit recurrence. More recent evidence brought to light complications associated with
synthetic mesh such as pain [35]. Mechanism of pain at the tissue-mesh plane has
been demonstrated as nerve growth within the weaves of meshes which then become
entrapped, leading to pain [36], and the possible need for mesh explantation.
References
1. Amid PK.Groin hernia repair: open techniques. World J Surg. 2005;29(8):1046–51.
2. Amid PK, Shulman AG, Lichtenstein IL.Critical scrutiny of the open tension-free hernio-
plasty. Am J Surg. 1993;165:369–71.
3. Amid PK. Lichtenstein tension-free hernioplasty: its inception, evolution, and principles.
Hernia. 2004;8:1–7.
4. Scott NW, McCormack K, Graham P, Go PM, Ross SJ, Grant AM.Open mesh versus non-mesh
for repair of femoral and inguinal hernia. Cochrane Database Syst Rev. 2002;(4):CD002197.
5. Simons MP, Aufenacker T, Bay Nielsoen M, etal. European Hernia Society guidelines on the
treatment of inguinal hernia in adult patients. Hernia. 2009;13:343–403.
6. Amid PK. New understanding of the causes and surgical treatment of postherniorrhaphy
inguinodynia and orchialgia. J Am Coll Surg. 2007;205:381–5.
7. Peiper C, Junge K, Klinge U, Strehlau E, Ottinger A, Schumpelick V.Is there a risk of infertility
after inguinal hernia repair? Experimental studies in pig and rabbit. Hernia. 2006;10(1):7–12.
8. Fitzgibbons RJ Jr, Richards AT, Quinn TH.Open hernia repair. In: Souba WW, Fink MP,
Jurkovich GJ, Kaiser LR, Pearce WH, Pemberton JH, Soper NJ, editors. ACS surgery: principles and practice. NewYork: WebMD Professional Publishing; 2005. p.603–24.
9. O’neill SM, etal. Groin hernia repair: open techniques. In: Novitsky YW, editor. Hernia sur-
gery: current principles. Cham: Springer; 2016. p.437–49.
10. Bendavid R, Koch A, Iakovlev VV.The Shouldice repair 2016. In: Hope WW, Cobb WS,
Adrales GL, editors. The textbook of hernia. Cham: Springer International Publishing; 2017.
p.53–68.
11. Amid PK, Shulman AG, Lichtenstein IL.Local anesthesia for inguinal hernia repair: step-by-
step procedure. Ann Surg. 1994;220(6):735–7.
12. Lichtenstein IL, Shore JM.Simplied repair of femoral and recurrent inguinal hernias by a
“plug” technique. Am J Surg. 1974;128:439–44.
13. Shulman AG, Amid PK, Lichtenstein IL.The plug repair of 1402 recurrent inguinal hernias.
Arch Surg. 1990;125:265–7.
14. Gilbert AI.Chapter 177: Generations of the plug and patch repair: its development and lessons
from history. Mastery of surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.
p.1940–3.
15. Robbins AW, Rutkow IM. The mesh-plug hernioplasty. Surg Clin North Am.
1993;73(3):501–11.
16. Rutkow AW, Robbins IM. The Marlex mesh prex plug groin hernioplasty. Eur J Surg.
1998;164:549.
17. Rutkow AW, Robbins IM.The mesh plug technique for recurrent groin herniorrhaphy: a nine
year experience of 407 repairs. Surgery. 1998;124(5):844–7.
18. Cristaldi M, Pisacreta M, etal. Femoro-popliteal bypass occlusion following mesh-plug for
prevascular femoral hernia repair. Hernia. 1997;1:197–9.
19. Dieter RA.Mesh plug migration into scrotum: a new complication of hernia repair. Int Surg.
1999;84:57–9.
20. Jeans S, Williams G, Stephenson B.Migration after open mesh plug inguinal hernioplasty: a
review of the literature. Am Surg. 2004;70:298–9.
21. LeBlanc KA.Complications associated with the plug and patch method of inguinal hernior-
rhaphy. Hernia. 2001;5:135–8.
414
22. Aleri S, Rotandi F, etal. Inuence of preservation versus division of ilioinguinal, iliohypo-
gastric, and genital nerves during open mesh herniorrhaphy. Prospective multicenter study of
chronic pain. Ann Surg. 2006;243(4):553–8.
23. Wijsmuller AR, Lang JFM, etal. Surgical technique preventing chronic pain after Lichtenstein
hernia repair; state of the art vs. daily practice in the Netherlands. Hernia. 2007;11:147–51.
24. Zwaans WAR, Verhagen T, Wouters L, Loos MJA, Roumen RMH, Scheltinga MRM.Groin
pain characteristics and recurrence rates: three-year results of a randomized controlled trial
comparing self-gripping Progrip mesh and sutured polypropylene mesh for open inguinal hernia repair. Ann Surg. 2018;267(6):1028–33.
25. Sanders DL, Waydia S.A systematic review of randomised control trials assessing mesh xa-
tion in open inguinal hernia repair. Hernia. 2014;18:165–76.
26. Kingsnorth A, Gingell-Littlejohn M, Nienhuijs S, etal. Randomized controlled multicenter
international clinical trial of self-gripping Parietex ProGrip polyester mesh versus lightweight
polypropylene mesh in open inguinal hernia repair: interim results at 3 months. Hernia.
2012;16:287–94.
27. Weyhe D, Belyaev O, Muller C, etal. Improving outcomes in hernia repair by the use of light
meshes: a comparison of different implant constructions based on a critical appraisal of the
literature. World J Surg. 2007;31(1):234–44.
28. Verhagen T, Zwaans WA, Loos MJ, et al. Randomized clinical trial comparing self-grip-
ping mesh with a standard polypropylene mesh for open inguinal hernia repair. Br J Surg.
2016;103:812–8.
29. Bendavid R.The need for mesh. In: Bendavid R, editor. Prosthesis and abdominal wall her-
nias. Austin: RG Landes Co; 1994. p.116–22.
30. Devlin HB, Gillen PHA, Waxman BP, MacNay RA.Short stay surgery for inguinal hernia:
experience of the Shouldice operation, 1970-1982. Br J Surg. 1986;73:123–4.
31. Simons MP, Kleijnen J, Van Geldere D, Hoitsma HFW, Obertop H.Role of the Shouldice tech-
nique in inguinal hernia repair: a systematic review of controlled trials and a meta-analysis. Br
J Surg. 1996;83(6):734–8.
32. Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, Moschetti I. Shouldice tech-
nique versus other open techniques for inguinal hernia repair. Cochrane Database Syst Rev.
2012;(4):CD001543.
33. Malik A, Bell CM, Stukel TA, Urbach DR. Recurrence of inguinal hernias repaired in a
large hernia surgical specialty hospital and general hospitals in Ontario, Canada. Can J Surg.
2016;59(1):19–25.
34. Dirksen CD, Beets GL, Go PM, Geisler FE, Baeten CG, Kootstra G.Bassini repair compared
with laparoscopic repair for primary inguinal hernia: a randomised controlled trial. Eur J Surg.
1998;164(6):439–47.
35. Magnusson N, Gunnarsson U, Nordin P, Smedberg S, Hedberg M, Sandblom G.Reoperation
for persistent pain after groin hernia surgery: a population based study. Hernia. 2015;19:45–51.
36. Bendavid R, Koch A, Morrison J, Petersen K, Grischkan D, Iakovlev V.A mechanism of mesh-
related post-herniorrhaphy neuralgia. Hernia. 2016;20(3):357–65.
A. Bates and S. Docimo Jr.
MIS Techniques: Lap TAPP andrTAPP
30
EdmundoInga-Zapata andFernandoGarcía
Introduction
The transabdominal preperitoneal approach (TAPP) was described more than
25years ago by several surgeons [1], and although the main principles are kept,
there are several variations and details worth mentioning [2]. Diverse technical
details have emerged from formal research and surgical social media [3, 4] that are
important for successful outcomes.
While the TEP technique goes directly to the preperitoneal space, the TAPP technique reaches the same preperitoneal space after rst entering the peritoneal cavity.
Despite TAPP being considered as more invasive and taking longer to perform than
TEP [5], it is surgically straightforward when it comes to understanding and learning the anatomy and the complexity of the repair; for this reason many surgeons see
it as the rst choice when learning MIS hernia repair [6, 7].
Over the last three decades the TAPP technique has evolved and has been rened,
with successful innovations including central aspects like xation and mesh types,
but also creative and interesting (although never widely adopted) like combined
approach [8], dissection aided by water [9], preperitoneal anesthetic injection to
decrease pain [10], and self-expanding mesh [11]. Therefore, we decided to include
the more relevant steps proposed by many groups to reduce recurrences and minimize complications.
E. Inga-Zapata, M.D., M.Sc, F.A.C.S. (*)
Surgical Andean Group, Lima, Peru
F. García, M.D., F.A.C.S.
John Peter Smith Hospital, Fort Worth, TX, USA
e-mail: surgmdfg@aol.com
© Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2019
S. S. Davis Jr. et al. (eds.), The SAGES Manual of Hernia Surgery,
https://doi.org/10.1007/978-3-319-78411-3_30
415
416
E. Inga-Zapata and F. García
Preoperative Aspects
The patient is placed supine with arms tucked. The surgeon stands on the side opposite the hernia with the monitor near the feet of the bed facing the surgeon. The
TAPP repair has been performed with all the types of anesthesia: general, regional
[12, 13], and even with only local anesthesia plus sedation [14]; nonetheless, the
most common practice is to use general anesthesia [15] because it guarantees more
relaxation of the abdominal wall (Fig.30.1).
Laparoscopic hernia repairs are less dynamic than other abdominal major laparoscopic interventions; nonetheless, it is important to secure the patient well to the
operating room table so that rotation and Trendelenburg can be used and to allow
gravity to move bowel cephalad and allow for better exposure of the intra- abdominal
groin region, particularly important in TAPP in comparison to TEP.
Although conservative surgeons probably favor a Foley catheter to guarantee bladder emptiness as a mean to secure and facilitate dissection of the space of Retzius,
there is the counterpart emerging position toward no longer use Foley catheter by
default in all patients, but only optionally in cases expected to take longer than usual
[16] and simply prevent the patient to void the bladder right before surgery [17, 18].
Fig. 30.1 Patient position
and OR distribution. Arms
tucked and surgeon
contralateral to hernia site
30 MIS Techniques: Lap TAPP andrTAPP
417
Operative Aspects
Port position will be according to surgeon training and experience. One way to set
up the ports is by looking for triangulation of the instruments, having the camera
port placed at the umbilicus (to take advantage of the umbilicus) and two other
lower prole ports lateral to the camera, to the right and left, for both hands.
Another common port conguration is in the classical TEP setup, in vertical
midline position, having the camera at the umbilicus, and the two other ports below
and in line downward. Although the surgeon will work with instruments in parallel
(sacricing triangulation), they will nd it may be more ergonomic (Fig.30.2).
The surgical gesture entails grasping, pulling, scissoring, traction, and countertraction. The goal is a proper dissection, and most surgeons use an atraumatic
grasper in the nondominant hand and scissors or an atraumatic gaper in the dominant hand. A tacker or needle driver is also used for peritoneal closure and often for
mesh xation. Minor bleeding is controlled by cauterizing and can be complemented by pressure with a gauze and better if humidied to more easily and gently
wiping the lm blood cloths out [19, 20]. Aspiration is barely needed, but it is convenient to have an aspirator always ready.
Development ofthePeritoneal Pocket
After port placement and inspection of the contralateral groin, the peritoneum is
incised, following an imaginary line starting close to the anterior iliac spine, horizontally toward the midline. Different styles for opening the peritoneum have been
Fig. 30.2 Port positions: the classic triangulating position (left image) and some variants (middle
and right images)
418
E. Inga-Zapata and F. García
described: transverse, curved cephalad convex, and an “s”-shaped incision [21].
Many favor the transverse incision. The peritoneum is incised, and the peritoneal
space is developed in large part with blunt dissection combined with sharp or electrocautery dissection by scissor or hook (Fig.30.3).
As the peritoneum is opened and the preperitoneal space developed, a thorough
knowledge of the anatomy is essential. The well-known critical view of safety
(CVS) for cholecystectomy [22] has its sister in the critical view of the myopectineal orice (CVMPO) [23], widely accepted and described in a previous chapter. The
principles of the CVMPO were developed after years of research and academic
exchange in surgical social media. Adherence to these principles ensures identication of critical anatomical landmarks and a successful endoscopic TAPP repair,
whether laparoscopic or robotic (Fig.30.4).
The development of the peritoneal ap from the anterior superior iliac spine
region to the umbilical ligament region may be interrupted in the middle by the cord
and its parietal peritoneum if there is an indirect sac. Because it takes time, patience,
and precision to develop a peritoneal opening in a bloodless fashion, it is helpful to
start the dissection laterally, where the space is more easily created by means of
gentle traction and countertraction. The pubic tubercle and Cooper’s ligament are
Fig. 30.3 Types of peritoneal openings: transverse (horizontally), convex shaped, and “s” shaped
Fig. 30.4 Two spaces of dissection (blue) with a midstructure and line of peritoneal edge
30 MIS Techniques: Lap TAPP andrTAPP
419
found medially and used as landmarks for dissection. The rst main danger zone to
pay attention to is the connection between the upper and lower venous systems
called the corona mortis [24]. About this anatomical landmark, it is interesting to
see that the less insufating pressure you work with, the more visible the corona
mortis becomes [25].
Gentle grasping of the peritoneum to pull it away from adherent fat with concomitant sweeping of the areolar attachments and countertraction with the opposite
hand/instrument is key to dissecting out the spermatic cord, vas deferens, and any
indirect sac. The medial (not median) umbilical ligaments could be but do not necessarily need to be transected and are easily pushed away when dissecting. Options
to treat the sac include simple peeling off of the cord until a point where our cephalad peritoneal traction does not move the cord.
For very large indirect sacs, amputation of the sac with adequate parietalization
and closure of the peritoneal defect is an option. Special care needs to be given to
cord lipomas whenever they arise because they might be a reason for patient discomfort or a feeling of a persistent hernia; therefore, removal is advised.
Unlike the TEP approach where the type of hernia ends up being determined
only after a careful dissection during the procedure itself, the TAPP approach offers
immediate and workless identication of direct and indirect hernias on both sides,
being this probably its main advantage over the TEP technique. Nevertheless, this
diagnostic accuracy does not readily identify the third common type of groin hernia,
femoral. For this, special attention is needed with focused dissection in the area
below Cooper’s in the vicinity of the iliac vein where—again—we usually will nd
lipoma like tissue covering the femoral entrance and not necessarily a classic peritoneal sac.
In general, lipomas and lipoma-like tissues are usually found at the medial
umbilical ligaments, the base of indirect sacs, deep in indirect sacs, and outside
indirect sacs attached to the cord structures (Fig.30.5).
Fig. 30.5 Cord lipoma
found on TAPP