Page 16 - WJOLS - Laparoscopic Journal

Michael Angelo L Suñaz
preperi toneal (TAPP) repair has the advantage of identi­ complete dissection of the preperitoneal space is accom­
fying missed additional direct or femoral hernia during plished using instruments placed intra-abdominally via
the initial operation. 4 accessory ports. Direct sacs are reduced and indirect sacs
Phillips and McKernan described the totally extraperi­ are either dissected from the cord structures and reduced
toneal (TEP) technique of endoscopic hernioplasty. The or divided circumferentially at the internal ring, leaving
peritoneal cavity is not breached when performing this the distal sac in place. These were accomplished during
technique and the entire dissection is performed bluntly the course of the preperitoneal dissection. An appropri­
in the preperitoneal space using a balloon device or the ately sized prosthetic mesh is placed in the preperitoneal
tip of the laparoscope itself. This procedure requires space over the hernia defect, overlapping it widely and is
an advanced knowledge of the posterioranatomy of the either slit to accommodate the cord structures or placed
inguinal region. Upon completion of dissection, a 15 × 10 cm over them. The mesh is then fixed in place using the
mesh is stapled in place over the myopectineal orifice. 4 following landmarks: the symphysis pubis medially,
The mesh is placed in direct contact with the fascia transversalis fascia above the internal ring superiorly,
of the transversalis muscle in the preperitoneal space an arbitrary point approximately 1 cm medial to the
in both the TAPP and TEP repairs, allowing tissue in anterior superior iliac spine laterally, the iliopubic tract
growths which lead to the fixation of the mesh. This is inferolaterally, and Cooper’s ligament inferomedially
opposed to the IPOM technique wherein the mesh is before peritoneal closure over the mesh using either
merely being brought in contact to the peritoneum and staples or sutures, thereby preventing the mesh from
is prone to migrate. 4 coming in contact with intra-abdominal viscera. 2
Depending on the type of repair and expertize of the Intraperitoneal Onlay Mesh Laparoscopic
surgeon, recurrence after primary open inguinal herniorr­ Herniorrhaphy
haphy occurs in approximately 10% of patients. Open
repair of the recurrence is challenging because of already Laparoscopic hernia repair wherein the a prosthetic mesh
weakened tissues and obscured and distorted anatomy was placed directly onto the peritoneum overlapping the
leading to a failure rate of as high as 36%. Because of this, hernia defect widely rather than the preperitoneal space,
focus has been given on repairing these difficult recurrent leaving the hernia sac in place. The same landmarks as
hernias laparoscopically using a tension­free approach. described with the TAPP procedure were used for fixing
Some of the earlier reports suggested a low recurrence the prosthetic mesh in place. 2
rate of 0.5 to 5% when a laparoscopic approach was used. 3
Totally Extraperitoneal Laparoscopic
OBJECTIVES Herniorrhaphy (Extra)/(TEP)

• To evaluate the efficacy and safety of three laparo­ Laparoscopic hernia repair wherein the skin and fascia
scopic hernia repair techniques: TAPP, TEP and IPOM at the umbilicus are incised using an open laparoscopic
• Specifically, this review aims to: technique, leaving the underlying peritoneum intact.
– Determine which laparoscopic technique has The preperitoneal space is dissected beginning at the
lowest recurrence rate umbilicus and continuing inferiorly, creating a ‘pneu­
– Determine which laparoscopic technique has the moextraperitoneum’ using CO gas. Additional ports
2
least perioperative complications. were placed into the extraperitoneal space once the
space was sufficiently enlarged, allowing introduction
MATERIALS AND METHODS of laparoscopic instrumentation. The abdominal cavity
is not entered. Dissection is performed until the hernia
The database used in this study was PubMed and MeSH.
Search terms included: laparoscop*, inguinal, hernia, defect is encountered and the procedure continued in an
2
repair, TAPP, TEP and IPOM. identical fashion to the TAPP operation.
Study designs included in this study were prospective DISCUSSION
clinical studies and retrospective clinical studies.
1
Catani et al reported their experience on laparoscopic
DEFINITION OF TERMS hernioplasty using the IOPM repair in 56 patients. Thirty
patients had a monolateral hernia, nine of which were
Transabdominal Preperitoneal Laparoscopic recurrent. Twenty-six had bilateral hernias, six of which
Inguinal Herniorrhaphy
were recurrent. A total of 90 hernias were treated. The first
Laparoscopic hernia repair wherein the peritoneum then 32 cases were repaired with the ‘GORETEX Dual Mesh
is incised transversely above the hernia defect, and a Plus biomaterial with holes’. The ‘Corduroy’ type was used
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