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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1433_Библиотеки_им_академика_М_И_Перельмана.pdf
102
J.F. Kukleta
11.2 History of TAPP
learning curve.
11.3 The Standardized TAPP [7]
11.3.1 Pneumoperitoneum
contralateral groin and the remaining anterior aspect of intraabdominal content
(Figs. 11.1–11.3).
11.3.2 Dissection
The preperitoneal space is entered through a planned incision of the visceral
starts laterally in a fairly avascular plane supported by the “pneumodissection” of
CO
2
gas under a pressure of 12 mmHg. We enter the space of Bogros (Fig. 11.6).
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11 Transabdominal Preperitoneal Patch (TAPP)
Fig. 11.1 Left indirect inguinal hernia
Fig. 11.2 Left direct inguinal hernia
Fig. 11.3
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J.F. Kukleta
Fig. 11.5
Fig. 11.4
Fig. 11.6 Entering the space of Bogros on the right
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11 Transabdominal Preperitoneal Patch (TAPP)
Crossing the epigastric vessels in a medial direction, the endoabdominal fascia
a continuation of each other, because they are not on the same level [9]. Further
arch (Fig. 11.7) up to the landmark of the symphysis pubis. The dissection 1-2 cm
and laterally to the origin of the epigastric vessels and the inner inguinal ring,
11.10). Medial to the spermatic cord, a vascular anomaly of the arterial or venous
Fig. 11.7 Left direct hernia dissected
Fig. 11.8
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J.F. Kukleta
Fig. 11.9
Fig. 11.10 Delicate dissection in triangle of doom on the right, vas deferens
Fig. 11.11 N. cutaneus femoris lateralis on the left
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11 Transabdominal Preperitoneal Patch (TAPP)
Fig. 11.12 Genitofemoral nerve on the left
Fig. 11.13 Dissection of indirect sac on the left side
Fig. 11.14 Cord lipoma on the left side
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J.F. Kukleta
Fig. 11.15
Fig. 11.16
Fig. 11.17
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11 Transabdominal Preperitoneal Patch (TAPP)
canal. Laterally to the spermatic vessels a fat pad covers some nerves of the lumbar
nerve) (Figs. 11.11 and 11.12). This area is called the triangle of pain. A very thin
tissue layer covers both triangles and protects the fragile underlying structures in
parietal peritoneal leaf facilitates the recognition and preservation of the spermatic
thermal damage. After retraction of all hernia sacs and preperitoneal fat (Figs. 11.7
should be removed out of the inguinal canal because they are or may become
symptomatic (Fig. 11.14). In large direct hernias, the remaining defect after
retraction of the preperitoneal fat leaves a dead space behind. This predisposes to
seroma formation and represents a risk factor for potential mesh dislocation. The
in order to reduce this risk. The indirect sac should be retracted completely out the
11.3.3 Mesh Placement
an adequate mesh is inserted. According to the EHS [10] and the IEHS guidelines
2
11.3.4 Fixation
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J.F. Kukleta
Fig. 11.18
Fig. 11.19
Fig. 11.20
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11 Transabdominal Preperitoneal Patch (TAPP)
11.3.5 Peritoneal Closure
11.3.6 Closure of the Trocar Incisions
should be closed in layers [7].
11.4 The Advantage of the TAPP Technique
2
side facilitates anatomic orientation, improves correctness of the preoperative
and recurrent hernias, unilateral and bilateral, inguinal and femoral, in females
11.5 The Rationale of the TAPP Technique
importance of the surgeon’s performance in terms of delicate and atraumatic