Page 19 - Journal of Laparoscopic Surgery

WJOLS

A Comparative Randomized Parallel Group Study between the Classical TAPP Repair and Modified TAPP
classical transabdominal preperitoneal (TAPP) repair. This back in position with controlled de insufflations of pneu-
saves cost and operating time while achieving comparable moperitoneum. No attempt is made on peritoneal closure.
clinical outcome regarding bowel related complications and The repair and placement of mesh done in TAPP repair is
hernia recurrences as shown in follow-up. on anterior abdominal wall, from where the peritoneal flap is
With low recurrence and complication rate achieved harvested with its base at the line of reflection of peri to neum
with LIHR, emphasis is now on finer issues, like operating from posterior to anterior abdominal wall. On con trolled
time, incidence of seroma and chronic pain. The study also release of insufflations and loss of Trendelenburg position
compares the techniques in a randomized prospective fashion viscera glides along posterior wall and puts sequ ential pressure
to see whether any difference of statistical significance exists on the flap from below and presses it back in position against
on those parameters. the anterior wall. Weight of the viscera keeps it securely
Overall, it wants to test the validity of null hypothesis placed while rapid mesothelial healing takes place leaving
regarding clinical outcome between modified TAPP (non- no opportunity of direct contact between mesh and bowel.
closure of peritoneum) and classical TAPP (meticulous
closure of peritoneum). Surgical Technique
Patients were operated under general anesthesia in supine
PATIenTS And MeTHodS and 10 to 15° Trendelenburg position with operating side
Between August 2011 and July 2012, all patients with tilted up and prophylactic antibiotic given on induction.
bilateral inguinal hernia presented to us were assessed for Pneumoperitoneum was induced by supraumbilical veress
eligibility in the proposed study. Inclusion criteria were male needle insertion. One 10 mm port for optics was introduced
patients with bilateral hernia and suited for TAPP repair, here and two 5 mm ports introduced at mid clavicular line
aged more than 18 years and fit to undergo general anes- at the level and on either side of umbilicus to accommodate
thesia. Patients with recurrent hernia or with indication for operating instruments. In modified TAPP, initial curvilinear
concomitant surgery for other pathology or with past lower peritoneal incision starting at the level of anterior superior
abdominal surgery were excluded. The research protocol iliac spine laterally, is made 2 cm higher than in classical
TAPP to make the flap larger. Dissection of preperitoneal
was approved by the Institutional Ethics Committee of ESIC space was carried out in similar fashion with parietalization
Medical College and Postgraduate Institute of Medical of cord structure done adequately, the landmark for adequacy
Research, Joka, Kolkata (where the trial was conducted), is to dissect up to the point where vas deferens crosses medial
before the commencement of the trial. Informed consent umbilical ligament. A 10 × 15 cm prolene mesh trimmed lat-
was obtained before patients were included in the trial. One erally to comfortably sit in the space of Retzius and Bogros,
hundred and thirty hernias in 65 patients were randomized covering the myopectineal orifices is anchored to Cooper’s
using digit 1 and 2 with the option of repetitions to create ligament at two points by prolene sutures. Only in 27 cases
a random sequence of 130 digits. Two consecutive digits when we used tack to close the peritoneum, this two-point
formed a double digit randomization code which is allotted fixation of mesh was done by tack. When in place, the lower
to one patient. Digit 1 stood for classical repair and digit 2 margin of the mesh wedges at the line of dissected peritoneal
for modified TAPP. First digit of the code dictates treatment reflection inferiorly, while its superior margin stays below
option for right side while the second for the left. Randomi- the initial peritoneal incision. The peritoneal flap was held
zation codes for patients were kept in sealed envelopes in up by instrument while pneumoperitoneum is deflated in a
the custody of theater nurse. Prospective data entry sheets controlled fashion, till it is relaid back in position on anterior
were used for collection of data.
abdominal wall.
Modification of Technique with Rationale outcome Assessment

The basic principle of TAPP repair with wide dissection Primary end points were recurrence of hernia and any
of preperitoneal space and securely anchoring a large bowel related complications like intestinal obstruction and
(15 cm × 10 cm) prolene mesh to cover all myopectineal fistula. Presence or absence of recurrence was determined
orifices in the region remains same. However in order to by clinical examination in follow-up, aided by radiological
harvest a larger peritoneal flap, initial peritoneal incision is investigations like CT and US in selected cases. As regard
made 2 cm higher than normal. Good parietalization of the to the gastrointestinal complications, combination of clinical
cord keeps the lower margin of the mesh firmly wedged. history and examination backed up by radiology was used.
Only two-point fixation of the mesh to Cooper’s ligament Three secondary parameters were compared and analyzed
is done with 2-0 prolene suture. The peritoneal flap is relaid for any difference of statistical significance. Operating time,
World Journal of Laparoscopic Surgery, January-April 2014;7(1):16-22 17